Saunders NCLEX-RN Test Bank Questions
and Answers Practice Questions with
Solutions | Newest | Already Graded A+
1. The nurse is caring for a client with disseminated intravascular coagulation
(DIC). Which of the following statements by the client would be essential to
follow up?
1. "I prefer to receive my medication subcutaneously rather than
intramuscularly."
2. "I have been taking 1 aspirin every day since I had a myocardial infarction
(MI) 1 year ago."
3. "I held pressure on the puncture site for 5 minutes after the nurse drew blood
from my arm."
4. "I have avoided blowing my nose today because I have had 2 episodes of
epistaxis."
ANSWER: 2. "I have been taking 1 aspirin every day since I had a
myocardial infarction (MI) 1 year ago."
2. The nurse is caring for a client who has just returned from the radiology
department after having an upper gastrointestinal (UGI) series. Which of the
following actions should the nurse take first?
1. Administer the prescribed enema.
2. Give the prescribed multiple vitamin that was withheld prior to the
procedure.
3. Determine whether follow-up x-rays are to be taken.
4. Verify the preliminary test results.
ANSWER: 4. Verify the preliminary test results.
,3. The nurse is talking with a client who has schizophrenia. The client states, "I just
returned from Mars." Which of the following responses would be appropriate for
the nurse to make?
1. "I need to tell you that you cannot talk about silly things here."
2. "Why do you think you made that trip?"
3. "How does it feel to be back?"
4. "I am here to listen to your concerns."
ANSWER: 4. "I am here to listen to your concerns."
4. The nurse is assisting to admit a client with active pulmonary tuberculosis (TB).
Which of the following actions should the nurse take prior to the client's arrival?
1. Assign the client to a room with a client who has pertussis if a private room
is not available.
2. Have a particulate respirator mask available for client transport.
3. Have particulate respirator masks available for staff who care for the client.
4. Post a sign outside the room restricting pregnant women from entering the
room.
ANSWER: 3. Have particulate respirator masks available for staff who care
for the client.
5. The nurse is collecting data from an 85-year-old male client. Which of the
following statements would be essential to follow up?
1. "I find that it takes longer to do tasks such as balancing my checkbook."
2. "I feel some stomach discomfort after eating a large meal."
3. "I have awakened from sleep because of shortness of breath."
4. "I have a problem starting a strong stream of urine."
ANSWER: 3. "I have awakened from sleep because of shortness of breath."
,6. The nurse is observing a coworker suctioning a client with a tracheostomy. The
nurse should intervene if the coworker:
1. Applies suction as the catheter is being withdrawn
2. Wears a face shield throughout the procedure
3. Applies suction for 10 seconds at each pass of the catheter
4. Wears clean, nonsterile gloves throughout the procedure
ANSWER: 4. Wears clean, nonsterile gloves throughout the procedure
7. The nurse is caring for a client diagnosed with pertussis. Which of the following
actions should the nurse take when assisting the client to eat or giving
medications?
1. Wear a surgical mask
2. Wear an N95 respirator
3. Wear clean gloves only
4. Wear a gown and eye protection
ANSWER: 1. Wear a surgical mask
8. The nurse is talking with the parent of a 3-month-old client. The parent
expresses concern that the infant is unable to roll over. Which of the following
would be an appropriate response for the nurse to make?
1. "Your baby should be evaluated by a neurologist immediately."
2. "Most infants roll over by 6 months, so this is expected at 3 months."
3. "You should start physical therapy exercises right away."
4. "Infants who don't roll over by 4 months often have developmental delays."
ANSWER: 2. "Most infants roll over by 6 months, so this is expected at 3
months."
, 9. The nurse is assessing a client who has just been admitted with a diagnosis of
bipolar disorder, manic episode. Which of the following findings would the nurse
expect?
1. Psychomotor retardation and flat affect
2. Grandiose delusions and pressured speech
3. Somatic complaints and insomnia
4. Magical thinking and social withdrawal
ANSWER: 2. Grandiose delusions and pressured speech
10. The nurse is providing discharge teaching to a client with a new prescription
for warfarin. Which of the following statements by the client indicates a need for
further teaching?
1. "I will use an electric razor for shaving."
2. "I will avoid eating large amounts of green leafy vegetables."
3. "I will take ibuprofen if I get a headache."
4. "I will have my blood tested regularly as prescribed."
ANSWER: 3. "I will take ibuprofen if I get a headache."
11. The nurse is caring for a client who is 2 hours postoperative following a
thyroidectomy. Which of the following findings should the nurse report to the
provider immediately?
1. Client reports pain of 4 on a 0-10 scale
2. Blood pressure of 118/76 mm Hg
3. Client reports tingling around the mouth and fingers
4. Temperature of 37.8°C (100°F)
ANSWER: 3. Client reports tingling around the mouth and fingers
and Answers Practice Questions with
Solutions | Newest | Already Graded A+
1. The nurse is caring for a client with disseminated intravascular coagulation
(DIC). Which of the following statements by the client would be essential to
follow up?
1. "I prefer to receive my medication subcutaneously rather than
intramuscularly."
2. "I have been taking 1 aspirin every day since I had a myocardial infarction
(MI) 1 year ago."
3. "I held pressure on the puncture site for 5 minutes after the nurse drew blood
from my arm."
4. "I have avoided blowing my nose today because I have had 2 episodes of
epistaxis."
ANSWER: 2. "I have been taking 1 aspirin every day since I had a
myocardial infarction (MI) 1 year ago."
2. The nurse is caring for a client who has just returned from the radiology
department after having an upper gastrointestinal (UGI) series. Which of the
following actions should the nurse take first?
1. Administer the prescribed enema.
2. Give the prescribed multiple vitamin that was withheld prior to the
procedure.
3. Determine whether follow-up x-rays are to be taken.
4. Verify the preliminary test results.
ANSWER: 4. Verify the preliminary test results.
,3. The nurse is talking with a client who has schizophrenia. The client states, "I just
returned from Mars." Which of the following responses would be appropriate for
the nurse to make?
1. "I need to tell you that you cannot talk about silly things here."
2. "Why do you think you made that trip?"
3. "How does it feel to be back?"
4. "I am here to listen to your concerns."
ANSWER: 4. "I am here to listen to your concerns."
4. The nurse is assisting to admit a client with active pulmonary tuberculosis (TB).
Which of the following actions should the nurse take prior to the client's arrival?
1. Assign the client to a room with a client who has pertussis if a private room
is not available.
2. Have a particulate respirator mask available for client transport.
3. Have particulate respirator masks available for staff who care for the client.
4. Post a sign outside the room restricting pregnant women from entering the
room.
ANSWER: 3. Have particulate respirator masks available for staff who care
for the client.
5. The nurse is collecting data from an 85-year-old male client. Which of the
following statements would be essential to follow up?
1. "I find that it takes longer to do tasks such as balancing my checkbook."
2. "I feel some stomach discomfort after eating a large meal."
3. "I have awakened from sleep because of shortness of breath."
4. "I have a problem starting a strong stream of urine."
ANSWER: 3. "I have awakened from sleep because of shortness of breath."
,6. The nurse is observing a coworker suctioning a client with a tracheostomy. The
nurse should intervene if the coworker:
1. Applies suction as the catheter is being withdrawn
2. Wears a face shield throughout the procedure
3. Applies suction for 10 seconds at each pass of the catheter
4. Wears clean, nonsterile gloves throughout the procedure
ANSWER: 4. Wears clean, nonsterile gloves throughout the procedure
7. The nurse is caring for a client diagnosed with pertussis. Which of the following
actions should the nurse take when assisting the client to eat or giving
medications?
1. Wear a surgical mask
2. Wear an N95 respirator
3. Wear clean gloves only
4. Wear a gown and eye protection
ANSWER: 1. Wear a surgical mask
8. The nurse is talking with the parent of a 3-month-old client. The parent
expresses concern that the infant is unable to roll over. Which of the following
would be an appropriate response for the nurse to make?
1. "Your baby should be evaluated by a neurologist immediately."
2. "Most infants roll over by 6 months, so this is expected at 3 months."
3. "You should start physical therapy exercises right away."
4. "Infants who don't roll over by 4 months often have developmental delays."
ANSWER: 2. "Most infants roll over by 6 months, so this is expected at 3
months."
, 9. The nurse is assessing a client who has just been admitted with a diagnosis of
bipolar disorder, manic episode. Which of the following findings would the nurse
expect?
1. Psychomotor retardation and flat affect
2. Grandiose delusions and pressured speech
3. Somatic complaints and insomnia
4. Magical thinking and social withdrawal
ANSWER: 2. Grandiose delusions and pressured speech
10. The nurse is providing discharge teaching to a client with a new prescription
for warfarin. Which of the following statements by the client indicates a need for
further teaching?
1. "I will use an electric razor for shaving."
2. "I will avoid eating large amounts of green leafy vegetables."
3. "I will take ibuprofen if I get a headache."
4. "I will have my blood tested regularly as prescribed."
ANSWER: 3. "I will take ibuprofen if I get a headache."
11. The nurse is caring for a client who is 2 hours postoperative following a
thyroidectomy. Which of the following findings should the nurse report to the
provider immediately?
1. Client reports pain of 4 on a 0-10 scale
2. Blood pressure of 118/76 mm Hg
3. Client reports tingling around the mouth and fingers
4. Temperature of 37.8°C (100°F)
ANSWER: 3. Client reports tingling around the mouth and fingers
