The Ultimate and Complete Saunders Comprehensive Review for NCLEX
Study Guide 2025, Covering All NCLEX-RN and NCLEX-PN Core Nursing
Concepts, Medical-Surgical Nursing, Pharmacology, Maternal and Pediatric
Nursing, Mental Health Nursing, Critical Thinking and Clinical Judgment, Next
Generation NCLEX (NGN) Question Formats, Patient Prioritization, Safety
and Infection Control, Dosage Calculations, Practice Questions with Detailed
Rationales, Real Exam Scenarios, Step-by-Step Strategies, and Proven
Methods to Successfully Pass the NCLEX Exam on the First Attempt with
High Scores
Question 1: A nurse is caring for a client with heart failure who is receiving furosemide 40 mg
IV push. Which assessment finding requires immediate intervention by the nurse?
A. Blood pressure 110/70 mm Hg
B. Serum potassium 3.2 mEq/L
C. Urine output 30 mL/hr
D. Weight loss of 1 kg in 24 hours
CORRECT ANSWER: B. Serum potassium 3.2 mEq/L
RATIONALE: Furosemide is a loop diuretic that causes potassium excretion, placing the client at
risk for hypokalemia. A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0
mEq/L) and can cause life-threatening cardiac dysrhythmias, muscle weakness, and fatigue. This
requires immediate intervention such as potassium replacement and cardiac monitoring. The
other findings are expected or acceptable: blood pressure 110/70 mm Hg is within normal
limits, urine output 30 mL/hr meets minimum adequate output, and weight loss of 1 kg in 24
hours reflects expected fluid loss with diuretic therapy.
Question 2: The nurse is preparing to administer insulin aspart subcutaneously to a client with
type 1 diabetes mellitus. Which action should the nurse take first?
A. Verify the client's identity using two identifiers
B. Check the client's current blood glucose level
C. Rotate the injection site from the previous administration
D. Ensure the insulin is at room temperature
CORRECT ANSWER: A. Verify the client's identity using two identifiers
RATIONALE: According to the National Patient Safety Goals and the "rights of medication
administration," verifying the client's identity using two unique identifiers is the first and most
critical step before administering any medication to prevent wrong-patient errors. While
checking blood glucose, rotating sites, and ensuring proper insulin temperature are important
,nursing actions, they occur after confirming the correct client. Patient safety protocols prioritize
identity verification above all other preparatory steps.
Question 3: A nurse is assessing a postpartum client who is 2 hours after vaginal delivery.
Which finding should the nurse report to the health care provider immediately?
A. Fundus firm and at the umbilicus
B. Lochia rubra with small clots
C. Blood pressure 90/60 mm Hg with heart rate 110 beats/min
D. Temperature 99.8°F (37.7°C)
CORRECT ANSWER: C. Blood pressure 90/60 mm Hg with heart rate 110 beats/min
RATIONALE: A blood pressure of 90/60 mm Hg with tachycardia (heart rate 110 beats/min) in
the immediate postpartum period may indicate hypovolemia or early hemorrhagic shock,
requiring immediate intervention. These vital sign changes suggest compensatory mechanisms
for blood loss. A firm fundus at the umbilicus is expected at 2 hours postpartum, lochia rubra
with small clots is normal, and a temperature of 99.8°F (37.7°C) may reflect normal postpartum
dehydration or exertion during labor and is not immediately concerning.
Question 4: The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)
who has a prescription for oxygen therapy at 2 L/min via nasal cannula. Why should the nurse
avoid increasing the oxygen flow rate without a provider order?
A. High oxygen concentrations can cause oxygen toxicity in COPD clients
B. COPD clients rely on hypoxic drive for ventilation, and high oxygen may suppress respirations
C. Increased oxygen flow can cause nasal mucosa drying and epistaxis
D. Higher flow rates increase the risk of fire in the client's environment
CORRECT ANSWER: B. COPD clients rely on hypoxic drive for ventilation, and high oxygen may
suppress respirations
RATIONALE: Clients with chronic COPD often develop a blunted response to carbon dioxide and
rely on low oxygen levels (hypoxic drive) to stimulate breathing. Administering high
concentrations of oxygen can suppress this drive, leading to hypoventilation, carbon dioxide
retention, respiratory acidosis, and potentially respiratory arrest. While oxygen toxicity, mucosal
drying, and fire risk are valid concerns with oxygen therapy, the hypoxic drive phenomenon is
the primary reason for cautious oxygen administration in COPD clients.
Question 5: A nurse is teaching a client about warfarin therapy. Which statement by the client
indicates a need for further teaching?
,A. "I will use an electric razor instead of a blade razor."
B. "I will avoid foods high in vitamin K like spinach and broccoli."
C. "I will take my warfarin at the same time every day."
D. "I will report any unusual bruising or bleeding to my provider."
CORRECT ANSWER: B. "I will avoid foods high in vitamin K like spinach and broccoli."
RATIONALE: Clients taking warfarin should maintain a consistent intake of vitamin K-rich foods
rather than avoiding them entirely, because sudden decreases in vitamin K can increase
warfarin's anticoagulant effect and raise bleeding risk. The goal is dietary consistency to
maintain stable INR levels. Using an electric razor, taking warfarin at the same time daily, and
reporting unusual bleeding are all correct safety measures. Further teaching is needed to clarify
that vitamin K foods should be consumed consistently, not eliminated.
Question 6: The nurse is caring for a client who is experiencing acute chest pain. Which action
should the nurse take first?
A. Administer sublingual nitroglycerin as prescribed
B. Obtain a 12-lead electrocardiogram
C. Assess the client's airway, breathing, and circulation
D. Notify the health care provider immediately
CORRECT ANSWER: C. Assess the client's airway, breathing, and circulation
RATIONALE: Using the ABC (airway, breathing, circulation) priority framework, the nurse must
first assess and ensure the client's basic life functions are intact before implementing
interventions. Chest pain may indicate myocardial infarction, pulmonary embolism, or other life-
threatening conditions requiring immediate assessment of oxygenation and perfusion status.
While obtaining an ECG, administering nitroglycerin, and notifying the provider are critical
actions, they follow the initial ABC assessment to determine the client's immediate physiological
stability.
Question 7: A nurse is preparing to administer a blood transfusion to a client. Which action is
most important to prevent a transfusion reaction?
A. Administer the blood within 4 hours of removal from refrigeration
B. Use a blood filter with the transfusion tubing
C. Verify the blood product and client identity with another registered nurse
D. Monitor vital signs every 15 minutes during the first hour
CORRECT ANSWER: C. Verify the blood product and client identity with another registered
nurse
, RATIONALE: The most critical step to prevent a potentially fatal hemolytic transfusion reaction is
the two-nurse verification process to ensure the correct blood product is administered to the
correct client. This includes checking the client's name, medical record number, blood type, Rh
factor, crossmatch results, and expiration date. While using a filter, timing administration, and
monitoring vital signs are important safety measures, they do not prevent the most dangerous
error: administering incompatible blood.
Question 8: The nurse is caring for a client with a newly applied cast on the right leg. Which
assessment finding requires immediate notification of the health care provider?
A. Client reports mild discomfort at the cast site
B. Capillary refill of 3 seconds in the toes of the right foot
C. Client reports numbness and tingling in the right foot
D. Slight swelling of the toes compared to the left foot
CORRECT ANSWER: C. Client reports numbness and tingling in the right foot
RATIONALE: Numbness and tingling in the extremity distal to a cast may indicate neurovascular
compromise, such as compartment syndrome or nerve compression, which requires immediate
intervention to prevent permanent tissue damage. While mild discomfort, capillary refill of 3
seconds (borderline but acceptable), and slight swelling can be expected after cast application,
paresthesias are a red flag symptom. The nurse should also assess for pain out of proportion,
pallor, paralysis, and pulselessness (the 5 P's of compartment syndrome).
Question 9: A nurse is developing a care plan for a client with Alzheimer's disease who
wanders at night. Which intervention is most appropriate to ensure client safety?
A. Apply wrist restraints during nighttime hours
B. Place the client in a room near the nurses' station
C. Administer a sedative-hypnotic medication at bedtime
D. Lock the unit doors to prevent elopement
CORRECT ANSWER: B. Place the client in a room near the nurses' station
RATIONALE: Placing a wandering client with Alzheimer's disease near the nurses' station allows
for increased observation and timely intervention while maintaining the least restrictive
environment. Restraints increase agitation, fall risk, and violate ethical standards unless all other
interventions fail and specific criteria are met. Sedative-hypnotics can worsen confusion and
increase fall risk in older adults. While securing unit doors may be part of a comprehensive
safety plan, it is not the nurse's independent intervention and does not address individualized
monitoring needs.
Study Guide 2025, Covering All NCLEX-RN and NCLEX-PN Core Nursing
Concepts, Medical-Surgical Nursing, Pharmacology, Maternal and Pediatric
Nursing, Mental Health Nursing, Critical Thinking and Clinical Judgment, Next
Generation NCLEX (NGN) Question Formats, Patient Prioritization, Safety
and Infection Control, Dosage Calculations, Practice Questions with Detailed
Rationales, Real Exam Scenarios, Step-by-Step Strategies, and Proven
Methods to Successfully Pass the NCLEX Exam on the First Attempt with
High Scores
Question 1: A nurse is caring for a client with heart failure who is receiving furosemide 40 mg
IV push. Which assessment finding requires immediate intervention by the nurse?
A. Blood pressure 110/70 mm Hg
B. Serum potassium 3.2 mEq/L
C. Urine output 30 mL/hr
D. Weight loss of 1 kg in 24 hours
CORRECT ANSWER: B. Serum potassium 3.2 mEq/L
RATIONALE: Furosemide is a loop diuretic that causes potassium excretion, placing the client at
risk for hypokalemia. A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0
mEq/L) and can cause life-threatening cardiac dysrhythmias, muscle weakness, and fatigue. This
requires immediate intervention such as potassium replacement and cardiac monitoring. The
other findings are expected or acceptable: blood pressure 110/70 mm Hg is within normal
limits, urine output 30 mL/hr meets minimum adequate output, and weight loss of 1 kg in 24
hours reflects expected fluid loss with diuretic therapy.
Question 2: The nurse is preparing to administer insulin aspart subcutaneously to a client with
type 1 diabetes mellitus. Which action should the nurse take first?
A. Verify the client's identity using two identifiers
B. Check the client's current blood glucose level
C. Rotate the injection site from the previous administration
D. Ensure the insulin is at room temperature
CORRECT ANSWER: A. Verify the client's identity using two identifiers
RATIONALE: According to the National Patient Safety Goals and the "rights of medication
administration," verifying the client's identity using two unique identifiers is the first and most
critical step before administering any medication to prevent wrong-patient errors. While
checking blood glucose, rotating sites, and ensuring proper insulin temperature are important
,nursing actions, they occur after confirming the correct client. Patient safety protocols prioritize
identity verification above all other preparatory steps.
Question 3: A nurse is assessing a postpartum client who is 2 hours after vaginal delivery.
Which finding should the nurse report to the health care provider immediately?
A. Fundus firm and at the umbilicus
B. Lochia rubra with small clots
C. Blood pressure 90/60 mm Hg with heart rate 110 beats/min
D. Temperature 99.8°F (37.7°C)
CORRECT ANSWER: C. Blood pressure 90/60 mm Hg with heart rate 110 beats/min
RATIONALE: A blood pressure of 90/60 mm Hg with tachycardia (heart rate 110 beats/min) in
the immediate postpartum period may indicate hypovolemia or early hemorrhagic shock,
requiring immediate intervention. These vital sign changes suggest compensatory mechanisms
for blood loss. A firm fundus at the umbilicus is expected at 2 hours postpartum, lochia rubra
with small clots is normal, and a temperature of 99.8°F (37.7°C) may reflect normal postpartum
dehydration or exertion during labor and is not immediately concerning.
Question 4: The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)
who has a prescription for oxygen therapy at 2 L/min via nasal cannula. Why should the nurse
avoid increasing the oxygen flow rate without a provider order?
A. High oxygen concentrations can cause oxygen toxicity in COPD clients
B. COPD clients rely on hypoxic drive for ventilation, and high oxygen may suppress respirations
C. Increased oxygen flow can cause nasal mucosa drying and epistaxis
D. Higher flow rates increase the risk of fire in the client's environment
CORRECT ANSWER: B. COPD clients rely on hypoxic drive for ventilation, and high oxygen may
suppress respirations
RATIONALE: Clients with chronic COPD often develop a blunted response to carbon dioxide and
rely on low oxygen levels (hypoxic drive) to stimulate breathing. Administering high
concentrations of oxygen can suppress this drive, leading to hypoventilation, carbon dioxide
retention, respiratory acidosis, and potentially respiratory arrest. While oxygen toxicity, mucosal
drying, and fire risk are valid concerns with oxygen therapy, the hypoxic drive phenomenon is
the primary reason for cautious oxygen administration in COPD clients.
Question 5: A nurse is teaching a client about warfarin therapy. Which statement by the client
indicates a need for further teaching?
,A. "I will use an electric razor instead of a blade razor."
B. "I will avoid foods high in vitamin K like spinach and broccoli."
C. "I will take my warfarin at the same time every day."
D. "I will report any unusual bruising or bleeding to my provider."
CORRECT ANSWER: B. "I will avoid foods high in vitamin K like spinach and broccoli."
RATIONALE: Clients taking warfarin should maintain a consistent intake of vitamin K-rich foods
rather than avoiding them entirely, because sudden decreases in vitamin K can increase
warfarin's anticoagulant effect and raise bleeding risk. The goal is dietary consistency to
maintain stable INR levels. Using an electric razor, taking warfarin at the same time daily, and
reporting unusual bleeding are all correct safety measures. Further teaching is needed to clarify
that vitamin K foods should be consumed consistently, not eliminated.
Question 6: The nurse is caring for a client who is experiencing acute chest pain. Which action
should the nurse take first?
A. Administer sublingual nitroglycerin as prescribed
B. Obtain a 12-lead electrocardiogram
C. Assess the client's airway, breathing, and circulation
D. Notify the health care provider immediately
CORRECT ANSWER: C. Assess the client's airway, breathing, and circulation
RATIONALE: Using the ABC (airway, breathing, circulation) priority framework, the nurse must
first assess and ensure the client's basic life functions are intact before implementing
interventions. Chest pain may indicate myocardial infarction, pulmonary embolism, or other life-
threatening conditions requiring immediate assessment of oxygenation and perfusion status.
While obtaining an ECG, administering nitroglycerin, and notifying the provider are critical
actions, they follow the initial ABC assessment to determine the client's immediate physiological
stability.
Question 7: A nurse is preparing to administer a blood transfusion to a client. Which action is
most important to prevent a transfusion reaction?
A. Administer the blood within 4 hours of removal from refrigeration
B. Use a blood filter with the transfusion tubing
C. Verify the blood product and client identity with another registered nurse
D. Monitor vital signs every 15 minutes during the first hour
CORRECT ANSWER: C. Verify the blood product and client identity with another registered
nurse
, RATIONALE: The most critical step to prevent a potentially fatal hemolytic transfusion reaction is
the two-nurse verification process to ensure the correct blood product is administered to the
correct client. This includes checking the client's name, medical record number, blood type, Rh
factor, crossmatch results, and expiration date. While using a filter, timing administration, and
monitoring vital signs are important safety measures, they do not prevent the most dangerous
error: administering incompatible blood.
Question 8: The nurse is caring for a client with a newly applied cast on the right leg. Which
assessment finding requires immediate notification of the health care provider?
A. Client reports mild discomfort at the cast site
B. Capillary refill of 3 seconds in the toes of the right foot
C. Client reports numbness and tingling in the right foot
D. Slight swelling of the toes compared to the left foot
CORRECT ANSWER: C. Client reports numbness and tingling in the right foot
RATIONALE: Numbness and tingling in the extremity distal to a cast may indicate neurovascular
compromise, such as compartment syndrome or nerve compression, which requires immediate
intervention to prevent permanent tissue damage. While mild discomfort, capillary refill of 3
seconds (borderline but acceptable), and slight swelling can be expected after cast application,
paresthesias are a red flag symptom. The nurse should also assess for pain out of proportion,
pallor, paralysis, and pulselessness (the 5 P's of compartment syndrome).
Question 9: A nurse is developing a care plan for a client with Alzheimer's disease who
wanders at night. Which intervention is most appropriate to ensure client safety?
A. Apply wrist restraints during nighttime hours
B. Place the client in a room near the nurses' station
C. Administer a sedative-hypnotic medication at bedtime
D. Lock the unit doors to prevent elopement
CORRECT ANSWER: B. Place the client in a room near the nurses' station
RATIONALE: Placing a wandering client with Alzheimer's disease near the nurses' station allows
for increased observation and timely intervention while maintaining the least restrictive
environment. Restraints increase agitation, fall risk, and violate ethical standards unless all other
interventions fail and specific criteria are met. Sedative-hypnotics can worsen confusion and
increase fall risk in older adults. While securing unit doors may be part of a comprehensive
safety plan, it is not the nurse's independent intervention and does not address individualized
monitoring needs.
