Saunders NCLEX-RN Test Bank
Saunders NCLEX-RN Test Bank 1 Questions
And Answers(100% CORRECT ANSWERS)
WITH RATIONALES/ GUARANTEED PASS
GRADED A+
An HIV-positive child is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The
laboratory results show the CD4+ as 1000 cells/mm3. Which of the following nursing actions is
appropriate?
A) Contacting the physician
B) Administering the vaccine
C) Asking the laboratory to repeat the CD4+ test
D) Informing the child's mother that the vaccine must not be administered at this time –
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Correct Answer :Answer: B
Rationale:
The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3,
the nurse would administer the vaccine. Contacting the physician, asking the laboratory to repeat the
CD4+ test, and telling the mother that the vaccine should not be administered at this time are all
incorrect in light of the results of the CD4+ count.
A client in a manic state emerges from her room and quickly enters the dayroom. She announces to
the group that she is the star of a burlesque show and will begin her performance shortly. The priority
nursing action is to:
A) Ask the client to go to her room and to change her clothes
B) Tell the client firmly that burlesque shows are not allowed in the nursing unit
C) Tell the client that her bathroom privileges are being suspended because of her behavior
D) Quietly and firmly assist the client to her room and help her dress in appropriate clothes –
Correct Answer :Answer: D
Rationale:
A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is
highly excitable. The nurse must take control without creating increased stress or anxiety in the client.
Taking a quiet, firm approach while distracting the client (i.e., walking her to her room and helping her
dress appropriately) achieves the goal of preserving her psychosocial integrity. Suspending the client's
bathroom privileges because of behavior, having the client change her clothes and telling the client
that burlesque shows are not allowed in the nursing unit will all increase the client's anxiety.
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my
coffin." Which response by the nurse is therapeutic?
A) "Do you think that having asthma will kill you?"
B) "You seem very distressed at learning that you have asthma."
C) "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your
coffin.'"
D) "Asthma is a very treatable condition, but it's important to learn how to properly administer your
medications. Let's practice with your inhalant." –
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
Correct Answer :Answer: B
Rationale:
A clients who has learned that he or she has a chronic illness may exhibit denial, anger, or sarcasm
because of the fear associated with such illnesses. It is important for the nurse to convey an accepting
attitude as a means of enhancing mutual respect and trust. Stating, "You seem very distressed at
learning that you have asthma" paraphrases the client's words and focuses on the client's feelings.
"Do you think that having asthma will kill you?" reflects and paraphrases the client's words but is
somewhat sarcastic. "Asthma is a very treatable condition, but it's important to learn how to properly
administer your medications. Let's practice with your inhalant" lectures the client and does not deal
directly with expressed concerns. "I'm not going to work with you if you can't view this as a challenge
rather than as a 'nail in your coffin'" is punitive, threatens the client, and sarcastically quotes the
client's words.
During a preoperative assessment, a nurse notices the client is crying. In light of this observation,
which statement by the nurse is appropriate?
A) "You seem upset. Would you rather be alone?"
B) "You're crying. Tell me more about how you are feeling."
C) "Your surgeon is the best and has done many of these operations."
D) "Crying before a serious operation is common, but everything will be okay." –
Correct Answer :Answer: B
Rationale:
Taking time to discuss the client's concerns is as important a nursing action in many instances as any
intervention for physical care. Therapeutic communication in this situation involves focusing on the
client's nonverbal cues and encouraging the client to express feelings or concerns about surgery.
Changing the subject and avoiding the client are techniques that also block communication with the
client. False reassurance also blocks communication with the client.
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head
say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this
client?
A) Ineffective coping skills
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
B) Perceptual disturbances
C) Chronic low self-esteem
D) Risk for self-directed violence –
Correct Answer :Answer: D
Rationale:
The altered perceptions and cognitive distortions experienced by the client with schizophrenia put the
client at risk for self-harm. A fundamental responsibility of the nurse is to provide a safe environment
for this client and others. Although ineffective coping skills, disturbed perceptual ability, and low self-
esteem may be appropriate concerns, the risk for self-directed violence is the priority.
A client who was recently sexually assaulted is self-contained and calm. The client says to the nurse, "It
doesn't seem real." Which defense mechanism is the client using?
A) Denial
B) Projection
C) Rationalization
D) Intellectualization –
Correct Answer :Answer: A
Rationale:
Denial is a common reaction by a victim of sexual assault. This defense mechanism is an adaptive and
protective reaction. Projection is blaming or scapegoating. Rationalization is justifying unacceptable
attributes. Intellectualization is the excessive use of abstract thinking or generalizations to decrease
painful thinking.
A nurse completes an initial assessment of a client admitted to the mental health unit. Which
assessment finding is the matter of greatest concern?
A) Bruises on the client's neck
B) The client's report of not sleeping well
C) The client's report of suicidal thoughts
A+ TEST BANK 4
Saunders NCLEX-RN Test Bank 1 Questions
And Answers(100% CORRECT ANSWERS)
WITH RATIONALES/ GUARANTEED PASS
GRADED A+
An HIV-positive child is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The
laboratory results show the CD4+ as 1000 cells/mm3. Which of the following nursing actions is
appropriate?
A) Contacting the physician
B) Administering the vaccine
C) Asking the laboratory to repeat the CD4+ test
D) Informing the child's mother that the vaccine must not be administered at this time –
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Correct Answer :Answer: B
Rationale:
The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3,
the nurse would administer the vaccine. Contacting the physician, asking the laboratory to repeat the
CD4+ test, and telling the mother that the vaccine should not be administered at this time are all
incorrect in light of the results of the CD4+ count.
A client in a manic state emerges from her room and quickly enters the dayroom. She announces to
the group that she is the star of a burlesque show and will begin her performance shortly. The priority
nursing action is to:
A) Ask the client to go to her room and to change her clothes
B) Tell the client firmly that burlesque shows are not allowed in the nursing unit
C) Tell the client that her bathroom privileges are being suspended because of her behavior
D) Quietly and firmly assist the client to her room and help her dress in appropriate clothes –
Correct Answer :Answer: D
Rationale:
A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is
highly excitable. The nurse must take control without creating increased stress or anxiety in the client.
Taking a quiet, firm approach while distracting the client (i.e., walking her to her room and helping her
dress appropriately) achieves the goal of preserving her psychosocial integrity. Suspending the client's
bathroom privileges because of behavior, having the client change her clothes and telling the client
that burlesque shows are not allowed in the nursing unit will all increase the client's anxiety.
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my
coffin." Which response by the nurse is therapeutic?
A) "Do you think that having asthma will kill you?"
B) "You seem very distressed at learning that you have asthma."
C) "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your
coffin.'"
D) "Asthma is a very treatable condition, but it's important to learn how to properly administer your
medications. Let's practice with your inhalant." –
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
Correct Answer :Answer: B
Rationale:
A clients who has learned that he or she has a chronic illness may exhibit denial, anger, or sarcasm
because of the fear associated with such illnesses. It is important for the nurse to convey an accepting
attitude as a means of enhancing mutual respect and trust. Stating, "You seem very distressed at
learning that you have asthma" paraphrases the client's words and focuses on the client's feelings.
"Do you think that having asthma will kill you?" reflects and paraphrases the client's words but is
somewhat sarcastic. "Asthma is a very treatable condition, but it's important to learn how to properly
administer your medications. Let's practice with your inhalant" lectures the client and does not deal
directly with expressed concerns. "I'm not going to work with you if you can't view this as a challenge
rather than as a 'nail in your coffin'" is punitive, threatens the client, and sarcastically quotes the
client's words.
During a preoperative assessment, a nurse notices the client is crying. In light of this observation,
which statement by the nurse is appropriate?
A) "You seem upset. Would you rather be alone?"
B) "You're crying. Tell me more about how you are feeling."
C) "Your surgeon is the best and has done many of these operations."
D) "Crying before a serious operation is common, but everything will be okay." –
Correct Answer :Answer: B
Rationale:
Taking time to discuss the client's concerns is as important a nursing action in many instances as any
intervention for physical care. Therapeutic communication in this situation involves focusing on the
client's nonverbal cues and encouraging the client to express feelings or concerns about surgery.
Changing the subject and avoiding the client are techniques that also block communication with the
client. False reassurance also blocks communication with the client.
A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head
say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this
client?
A) Ineffective coping skills
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
B) Perceptual disturbances
C) Chronic low self-esteem
D) Risk for self-directed violence –
Correct Answer :Answer: D
Rationale:
The altered perceptions and cognitive distortions experienced by the client with schizophrenia put the
client at risk for self-harm. A fundamental responsibility of the nurse is to provide a safe environment
for this client and others. Although ineffective coping skills, disturbed perceptual ability, and low self-
esteem may be appropriate concerns, the risk for self-directed violence is the priority.
A client who was recently sexually assaulted is self-contained and calm. The client says to the nurse, "It
doesn't seem real." Which defense mechanism is the client using?
A) Denial
B) Projection
C) Rationalization
D) Intellectualization –
Correct Answer :Answer: A
Rationale:
Denial is a common reaction by a victim of sexual assault. This defense mechanism is an adaptive and
protective reaction. Projection is blaming or scapegoating. Rationalization is justifying unacceptable
attributes. Intellectualization is the excessive use of abstract thinking or generalizations to decrease
painful thinking.
A nurse completes an initial assessment of a client admitted to the mental health unit. Which
assessment finding is the matter of greatest concern?
A) Bruises on the client's neck
B) The client's report of not sleeping well
C) The client's report of suicidal thoughts
A+ TEST BANK 4
