Saunders NCLEX-RN Test Bank
Saunders NCLEX-RN Test Bank 4 Questions
And Answers(100% CORRECT ANSWERS)
WITH RATIONALES/ GUARANTEED PASS
GRADED A+
The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25
seconds, the nurse notes that the client is confused for 20 minutes. The client does not know
the current location, does not know the current season, and has a headache. The nurse
documents the confusion and headache as which phase of the client's seizure activity?
1. Aural phase
2. Ictal phase
3. Postictal phase
4. Prodromal phase –
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Correct Answer :3. Postictal phase
A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The
client is able to verbalize the correct procedure for wound care but reports not adhering to
the ordered routine at home. What intervention does the nurse prioritize to promote proper
self care?
1. Assess the client's feelings about placement at a skilled nursing facility for care
2. Educate the client on the risks of tissue death if not properly cared for at home
3. Explore the client's abilities and motivation to perform care at home
4. Provide the client with the supplies needed to change dressings as recommended –
Correct Answer :3. Explore the client's abilities and motivation to perform care at home
A client with massive trauma and possible spinal cord injury is admitted to the emergency
department following a dirt bike accident. Which clinical manifestation does the nurse assess
to help best confirm a diagnosis of neurogenic shock?
1. Apical heart rate 48/min
2. Blood pressure 186/92 mm Hg
3. Cool, clammy skin
4. Temperature 100 F (37.7 C) tympanic –
Correct Answer :1. Apical heart rate 48/min
The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease
process and home management. Which statement by the client indicates comprehension of
teaching?
1. "Even with appropriate treatment joint damage and disability are inevitable."
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
2. "My arthritis can be resolved if I can improve my diet and lose weight."
3. "My methotrexate should be taken even when my joints aren't hurting."
4. "When my joints hurt, I should rest frequently and try not to move them." –
Correct Answer :3. "My methotrexate should be taken even when my joints aren't hurting."
When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed
from the bedside commode, the plastic chest drainage unit accidently falls over and cracks.
The UAP immediately reports this incident to the nurse. What is the nurse's immediate action?
1. Clamp the tube close to the client's chest until a new chest drainage unit is set up
2. Notify the health care provider (HCP)
3. Place the distal end of the chest tube into a bottle of sterile saline
4. Position the client on the left side –
Correct Answer :3. Place the distal end of the chest tube into a bottle of sterile saline
The nurse reviews laboratory data for a client admitted to the emergency department with
chest pain. Which serum value requires the most immediate action by the nurse?
1. Glucose 200 mg/dL (11.1 mmol/L)
2. Hematocrit 38% (0.38)
3. Potassium 3.4 mEq/L (3.4 mmol/L)
4. Troponin 0.7 ng/mL (0.7 mcg/L) –
Correct Answer :4. Troponin 0.7 ng/mL (0.7 mcg/L)
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care
and symptom management. Which of the following client statements indicates a need for
further teaching?
1. "Daily range-of-motion exercises are important to keep my joints flexible."
2. "I can use a moist heat pack to help with joint stiffness."
3. "I should elevate my knees with pillows when I'm sleeping."
4. "I will make sure to rest in between activities throughout the day." –
Correct Answer :3. "I should elevate my knees with pillows when I'm sleeping."
The spouse of an immunocompromised client is diagnosed with influenza virus infection. The
spouse asks the office nurse how long contact with the client should be avoided to prevent
the infection from spreading. What is the nurse's most appropriate response?
1. "Avoid close contact for about a week."
2. "It's impossible to avoid contact with the client. Just wash your hands often."
3. "You are sick already, and so you are not contagious anymore."
4. "You don't have to worry as long as the client has received the influenza vaccination." –
Correct Answer :1. "Avoid close contact for about a week."
The home care nurse visits the house of an elderly client. Which assessment finding requires
immediate intervention?
1. The client cannot remember what was done yesterday
2. The client has a painful red area on the buttocks
3. The client has new dependent edema of the feet
4. The client has strong, foul smelling urine –
A+ TEST BANK 4
Saunders NCLEX-RN Test Bank 4 Questions
And Answers(100% CORRECT ANSWERS)
WITH RATIONALES/ GUARANTEED PASS
GRADED A+
The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25
seconds, the nurse notes that the client is confused for 20 minutes. The client does not know
the current location, does not know the current season, and has a headache. The nurse
documents the confusion and headache as which phase of the client's seizure activity?
1. Aural phase
2. Ictal phase
3. Postictal phase
4. Prodromal phase –
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Correct Answer :3. Postictal phase
A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The
client is able to verbalize the correct procedure for wound care but reports not adhering to
the ordered routine at home. What intervention does the nurse prioritize to promote proper
self care?
1. Assess the client's feelings about placement at a skilled nursing facility for care
2. Educate the client on the risks of tissue death if not properly cared for at home
3. Explore the client's abilities and motivation to perform care at home
4. Provide the client with the supplies needed to change dressings as recommended –
Correct Answer :3. Explore the client's abilities and motivation to perform care at home
A client with massive trauma and possible spinal cord injury is admitted to the emergency
department following a dirt bike accident. Which clinical manifestation does the nurse assess
to help best confirm a diagnosis of neurogenic shock?
1. Apical heart rate 48/min
2. Blood pressure 186/92 mm Hg
3. Cool, clammy skin
4. Temperature 100 F (37.7 C) tympanic –
Correct Answer :1. Apical heart rate 48/min
The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease
process and home management. Which statement by the client indicates comprehension of
teaching?
1. "Even with appropriate treatment joint damage and disability are inevitable."
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
2. "My arthritis can be resolved if I can improve my diet and lose weight."
3. "My methotrexate should be taken even when my joints aren't hurting."
4. "When my joints hurt, I should rest frequently and try not to move them." –
Correct Answer :3. "My methotrexate should be taken even when my joints aren't hurting."
When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed
from the bedside commode, the plastic chest drainage unit accidently falls over and cracks.
The UAP immediately reports this incident to the nurse. What is the nurse's immediate action?
1. Clamp the tube close to the client's chest until a new chest drainage unit is set up
2. Notify the health care provider (HCP)
3. Place the distal end of the chest tube into a bottle of sterile saline
4. Position the client on the left side –
Correct Answer :3. Place the distal end of the chest tube into a bottle of sterile saline
The nurse reviews laboratory data for a client admitted to the emergency department with
chest pain. Which serum value requires the most immediate action by the nurse?
1. Glucose 200 mg/dL (11.1 mmol/L)
2. Hematocrit 38% (0.38)
3. Potassium 3.4 mEq/L (3.4 mmol/L)
4. Troponin 0.7 ng/mL (0.7 mcg/L) –
Correct Answer :4. Troponin 0.7 ng/mL (0.7 mcg/L)
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care
and symptom management. Which of the following client statements indicates a need for
further teaching?
1. "Daily range-of-motion exercises are important to keep my joints flexible."
2. "I can use a moist heat pack to help with joint stiffness."
3. "I should elevate my knees with pillows when I'm sleeping."
4. "I will make sure to rest in between activities throughout the day." –
Correct Answer :3. "I should elevate my knees with pillows when I'm sleeping."
The spouse of an immunocompromised client is diagnosed with influenza virus infection. The
spouse asks the office nurse how long contact with the client should be avoided to prevent
the infection from spreading. What is the nurse's most appropriate response?
1. "Avoid close contact for about a week."
2. "It's impossible to avoid contact with the client. Just wash your hands often."
3. "You are sick already, and so you are not contagious anymore."
4. "You don't have to worry as long as the client has received the influenza vaccination." –
Correct Answer :1. "Avoid close contact for about a week."
The home care nurse visits the house of an elderly client. Which assessment finding requires
immediate intervention?
1. The client cannot remember what was done yesterday
2. The client has a painful red area on the buttocks
3. The client has new dependent edema of the feet
4. The client has strong, foul smelling urine –
A+ TEST BANK 4
