Saunders NCLEX-RN Test Bank
Saunders NCLEX-RN Test Bank 3 Questions
And Answers(100% CORRECT ANSWERS)
WITH RATIONALES/ GUARANTEED PASS
GRADED A+
A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic
leukemia. During the initial nursing assessment, which symptoms will this child most likely
exhibit?
A. Bone pain, pallor
B. Weakness, tremors
C. Nystagmus, anorexia
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
D. Fever, abdominal distention –
Correct Answer :A
Rationale:
Option A lists the most common presenting symptoms of leukemia. Leukemic cells invade the
bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic
fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain
and anemia results from decreased erythrocytes, causing pallor. Options B and C could be
associated with central nervous system disorders. Option D commonly occurs in children but
is not specific for leukemia.
Which preoperative nursing intervention should be included in the plan of care for an infant
with pyloric stenosis?
A. Monitor for signs of metabolic acidosis.
B. Estimate the quantity of diarrhea stools.
C. Place in a supine position after feeding.
D. Observe for projectile vomiting.
- Correct Answer :D
Rationale:
Projectile vomiting, the classic sign of pyloric stenosis, contributes to metabolic alkalosis.
Metabolic acidosis is the opposite imbalance from alkalosis and is not an expected finding. An
antidiarrheal agent is not indicated. Option C is dangerous because of the potential for
aspiration with frequent vomiting.
The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further
assessment reveals that he is concerned about his edematous facial features. Based on these
assessment findings, the nurse should plan interventions related to which nursing diagnosis?
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
A. Social isolation
B. Altered health maintenance
C. Knowledge deficit
D. Ineffective coping –
Correct Answer :A
Rationale:
Peer acceptance and body image are significant issues in the growth and development of
adolescents. Option A addresses the problem of a lack of contact with peers stemming from
his desire to protect his ego. Options B, C, and D are not supported by the assessment
finding.
An 89-year-old client is admitted to the rehabilitation unit after a hip fracture. When reviewing
the client's pre-fracture routine the client states, "I usually get up around 0800 and have
breakfast by 0900; I say my daily prayers between 1000 and 1030. I like lunch around 1300;
then a nap from 1400 to 1600. I generally eat supper around 1900." What is the nurse's best
response to the client's schedule?
A.
"We can try our best to work around your schedule."
B.
"Your physical therapy is scheduled for 1500 to 1600."
C.
"You will have to get your own supper if you want to eat that late."
D.
"Is there any way you could say your prayers between 1230 and 1300?" –
Correct Answer :D
Rationale:
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
The elderly have a routine that generally fits around their sleep-wake cycle, or their circadian
rhythm. The flexibility is around prayer time, since it is during the wake time. If the
rehabilitation therapy can be scheduled in the am, that is generally the time when they have
more energy. Trying the best, does not place the client's sleep-wake schedule as a priority.
While supper on the rehab unit may be before 1900, arrangements can be made to deliver a
tray later, or keep a tray warm
The nurse determines that a postoperative client's respiratory rate has increased from 18 to
24 breaths/min. Based on this assessment finding, what is the priority nursing action?
A.
Encourage the client to increase ambulation in the room.
B.
Offer the client a high-carbohydrate snack for energy.
C.
Force fluids to thin the client's pulmonary secretions.
D.
Determine if pain is causing the client's tachypnea. –
Correct Answer :D
Rationale:
Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased
respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is
rising above normal limits puts the client at risk for further oxygen desaturation. Option B can
increase the client's carbon metabolism, so an alternative source of energy, such as
Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory
congestion in a client with a poorly functioning cardiopulmonary system, placing the client at
risk of fluid overload
A+ TEST BANK 4
Saunders NCLEX-RN Test Bank 3 Questions
And Answers(100% CORRECT ANSWERS)
WITH RATIONALES/ GUARANTEED PASS
GRADED A+
A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic
leukemia. During the initial nursing assessment, which symptoms will this child most likely
exhibit?
A. Bone pain, pallor
B. Weakness, tremors
C. Nystagmus, anorexia
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
D. Fever, abdominal distention –
Correct Answer :A
Rationale:
Option A lists the most common presenting symptoms of leukemia. Leukemic cells invade the
bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic
fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain
and anemia results from decreased erythrocytes, causing pallor. Options B and C could be
associated with central nervous system disorders. Option D commonly occurs in children but
is not specific for leukemia.
Which preoperative nursing intervention should be included in the plan of care for an infant
with pyloric stenosis?
A. Monitor for signs of metabolic acidosis.
B. Estimate the quantity of diarrhea stools.
C. Place in a supine position after feeding.
D. Observe for projectile vomiting.
- Correct Answer :D
Rationale:
Projectile vomiting, the classic sign of pyloric stenosis, contributes to metabolic alkalosis.
Metabolic acidosis is the opposite imbalance from alkalosis and is not an expected finding. An
antidiarrheal agent is not indicated. Option C is dangerous because of the potential for
aspiration with frequent vomiting.
The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further
assessment reveals that he is concerned about his edematous facial features. Based on these
assessment findings, the nurse should plan interventions related to which nursing diagnosis?
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
A. Social isolation
B. Altered health maintenance
C. Knowledge deficit
D. Ineffective coping –
Correct Answer :A
Rationale:
Peer acceptance and body image are significant issues in the growth and development of
adolescents. Option A addresses the problem of a lack of contact with peers stemming from
his desire to protect his ego. Options B, C, and D are not supported by the assessment
finding.
An 89-year-old client is admitted to the rehabilitation unit after a hip fracture. When reviewing
the client's pre-fracture routine the client states, "I usually get up around 0800 and have
breakfast by 0900; I say my daily prayers between 1000 and 1030. I like lunch around 1300;
then a nap from 1400 to 1600. I generally eat supper around 1900." What is the nurse's best
response to the client's schedule?
A.
"We can try our best to work around your schedule."
B.
"Your physical therapy is scheduled for 1500 to 1600."
C.
"You will have to get your own supper if you want to eat that late."
D.
"Is there any way you could say your prayers between 1230 and 1300?" –
Correct Answer :D
Rationale:
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
The elderly have a routine that generally fits around their sleep-wake cycle, or their circadian
rhythm. The flexibility is around prayer time, since it is during the wake time. If the
rehabilitation therapy can be scheduled in the am, that is generally the time when they have
more energy. Trying the best, does not place the client's sleep-wake schedule as a priority.
While supper on the rehab unit may be before 1900, arrangements can be made to deliver a
tray later, or keep a tray warm
The nurse determines that a postoperative client's respiratory rate has increased from 18 to
24 breaths/min. Based on this assessment finding, what is the priority nursing action?
A.
Encourage the client to increase ambulation in the room.
B.
Offer the client a high-carbohydrate snack for energy.
C.
Force fluids to thin the client's pulmonary secretions.
D.
Determine if pain is causing the client's tachypnea. –
Correct Answer :D
Rationale:
Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased
respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is
rising above normal limits puts the client at risk for further oxygen desaturation. Option B can
increase the client's carbon metabolism, so an alternative source of energy, such as
Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory
congestion in a client with a poorly functioning cardiopulmonary system, placing the client at
risk of fluid overload
A+ TEST BANK 4
