TEST BANK FOR SAUNDERS COMPREHENSIVE
REVIEW FOR THE NCLEXRN EXAMINATION EXAM
QUESTIONS AND CORRECT ANSWERS (verified
answers) Q & A 2026
/INSTANT DOWNLOAD PDF
1. A nurse is caring for a client receiving morphine. Which assessment finding
requires immediate intervention?
A. Respiratory rate 10 breaths/min
B. Blood pressure 118/76 mmHg
C. Pain score 3/10
D. Pupils equal and reactive
Correct answer: A
Rationale: Morphine can cause respiratory depression. A respiratory rate of 10 is
below normal and indicates potential overdose requiring immediate intervention.
2. Which action should the nurse take first when a fire alarm sounds in the
hospital unit?
A. Evacuate ambulatory clients
B. Extinguish the fire if small
C. Close all doors and windows
D. Activate the fire alarm system
Correct answer: D
Rationale: The first priority is to activate the alarm (RACE protocol: Rescue, Alarm,
Contain, Extinguish/Evacuate).
,3. A client with heart failure is prescribed furosemide. Which lab value should
the nurse monitor closely?
A. Sodium
B. Potassium
C. Calcium
D. Hemoglobin
Correct answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss, increasing risk
for hypokalemia.
4. Which symptom is most indicative of hypoglycemia?
A. Fruity breath odor
B. Slow, deep respirations
C. Diaphoresis and tremors
D. Dry, hot skin
Correct answer: C
Rationale: Hypoglycemia stimulates the sympathetic nervous system causing
sweating and tremors.
5. A nurse is teaching a client about warfarin therapy. Which statement indicates
understanding?
A. “I will increase my intake of leafy green vegetables.”
B. “I will use an electric razor when shaving.”
C. “I will take aspirin for headaches.”
D. “I will double my dose if I miss one.”
Correct answer: B
Rationale: Warfarin increases bleeding risk; electric razors reduce injury risk.
,6. Which patient is at highest risk for developing pressure injuries?
A. A mobile postoperative patient
B. A client with diabetes and immobility
C. A client with hypertension
D. A client with seasonal allergies
Correct answer: B
Rationale: Immobility and diabetes impair circulation and skin integrity.
7. What is the priority nursing action for a client experiencing anaphylaxis?
A. Administer oral antihistamine
B. Give IM epinephrine
C. Start IV fluids slowly
D. Obtain allergy history
Correct answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis.
8. Which finding indicates fluid volume excess?
A. Dry mucous membranes
B. Decreased blood pressure
C. Jugular vein distention
D. Flat neck veins
Correct answer: C
Rationale: JVD is a sign of fluid overload and increased venous pressure.
9. A client is receiving oxygen via nasal cannula. Which action ensures safety?
A. Apply petroleum jelly to nostrils
B. Check oxygen tubing for kinks
, C. Place oxygen near open flame
D. Use wool blankets
Correct answer: B
Rationale: Ensuring unobstructed oxygen flow is essential for therapy effectiveness
and safety.
10. Which electrolyte imbalance is associated with Trousseau’s sign?
A. Hyperkalemia
B. Hypocalcemia
C. Hypernatremia
D. Hypomagnesemia
Correct answer: B
Rationale: Trousseau’s sign indicates low calcium levels.
11. A nurse is caring for a post-op client. Which sign indicates infection?
A. Bradycardia
B. Incision redness and warmth
C. Decreased WBC count
D. Hypothermia
Correct answer: B
Rationale: Local inflammation (redness, warmth) suggests infection.
12. What is the most important action when administering insulin?
A. Shake the vial vigorously
B. Verify the dosage with another nurse
C. Administer IM
D. Skip if blood glucose is normal
REVIEW FOR THE NCLEXRN EXAMINATION EXAM
QUESTIONS AND CORRECT ANSWERS (verified
answers) Q & A 2026
/INSTANT DOWNLOAD PDF
1. A nurse is caring for a client receiving morphine. Which assessment finding
requires immediate intervention?
A. Respiratory rate 10 breaths/min
B. Blood pressure 118/76 mmHg
C. Pain score 3/10
D. Pupils equal and reactive
Correct answer: A
Rationale: Morphine can cause respiratory depression. A respiratory rate of 10 is
below normal and indicates potential overdose requiring immediate intervention.
2. Which action should the nurse take first when a fire alarm sounds in the
hospital unit?
A. Evacuate ambulatory clients
B. Extinguish the fire if small
C. Close all doors and windows
D. Activate the fire alarm system
Correct answer: D
Rationale: The first priority is to activate the alarm (RACE protocol: Rescue, Alarm,
Contain, Extinguish/Evacuate).
,3. A client with heart failure is prescribed furosemide. Which lab value should
the nurse monitor closely?
A. Sodium
B. Potassium
C. Calcium
D. Hemoglobin
Correct answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss, increasing risk
for hypokalemia.
4. Which symptom is most indicative of hypoglycemia?
A. Fruity breath odor
B. Slow, deep respirations
C. Diaphoresis and tremors
D. Dry, hot skin
Correct answer: C
Rationale: Hypoglycemia stimulates the sympathetic nervous system causing
sweating and tremors.
5. A nurse is teaching a client about warfarin therapy. Which statement indicates
understanding?
A. “I will increase my intake of leafy green vegetables.”
B. “I will use an electric razor when shaving.”
C. “I will take aspirin for headaches.”
D. “I will double my dose if I miss one.”
Correct answer: B
Rationale: Warfarin increases bleeding risk; electric razors reduce injury risk.
,6. Which patient is at highest risk for developing pressure injuries?
A. A mobile postoperative patient
B. A client with diabetes and immobility
C. A client with hypertension
D. A client with seasonal allergies
Correct answer: B
Rationale: Immobility and diabetes impair circulation and skin integrity.
7. What is the priority nursing action for a client experiencing anaphylaxis?
A. Administer oral antihistamine
B. Give IM epinephrine
C. Start IV fluids slowly
D. Obtain allergy history
Correct answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis.
8. Which finding indicates fluid volume excess?
A. Dry mucous membranes
B. Decreased blood pressure
C. Jugular vein distention
D. Flat neck veins
Correct answer: C
Rationale: JVD is a sign of fluid overload and increased venous pressure.
9. A client is receiving oxygen via nasal cannula. Which action ensures safety?
A. Apply petroleum jelly to nostrils
B. Check oxygen tubing for kinks
, C. Place oxygen near open flame
D. Use wool blankets
Correct answer: B
Rationale: Ensuring unobstructed oxygen flow is essential for therapy effectiveness
and safety.
10. Which electrolyte imbalance is associated with Trousseau’s sign?
A. Hyperkalemia
B. Hypocalcemia
C. Hypernatremia
D. Hypomagnesemia
Correct answer: B
Rationale: Trousseau’s sign indicates low calcium levels.
11. A nurse is caring for a post-op client. Which sign indicates infection?
A. Bradycardia
B. Incision redness and warmth
C. Decreased WBC count
D. Hypothermia
Correct answer: B
Rationale: Local inflammation (redness, warmth) suggests infection.
12. What is the most important action when administering insulin?
A. Shake the vial vigorously
B. Verify the dosage with another nurse
C. Administer IM
D. Skip if blood glucose is normal
