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Saunders NCLEX-RN Test Bank Questions And Answers Practice
Exam 2026-2027 BANK QUESTIONS WITH DETAILED
VERIFIED ANSWERS EXAM QUESTIONS WILL COME
FROM HERE (100% CORRECT ANSWERS A+ GRADED
1. A nurse is caring for a client admitted with a diagnosis of acute
myocardial infarction. The client suddenly develops a loud holosystolic
murmur at the fifth intercostal space, midclavicular line. What
complication does the nurse suspect?
A. Pericarditis
B. Ventricular septal rupture
C. Mitral valve prolapse
D. Aortic stenosis
Answer: B. Ventricular septal rupture. A new loud holosystolic murmur
at the left sternal border following a myocardial infarction suggests a
rupture of the interventricular septum, a serious mechanical
complication that creates a left-to-right shunt. Pericarditis produces a
friction rub, not a holosystolic murmur. Mitral valve prolapse typically
presents with a mid-systolic click, and aortic stenosis produces a
systolic ejection murmur heard best at the right upper sternal border.
2. A client is receiving a continuous heparin infusion for a deep vein
thrombosis. The current activated partial thromboplastin time is 95
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seconds, with a control value of 30 seconds. What is the priority nursing
action?
A. Increase the infusion rate per protocol
B. Stop the heparin infusion
C. Administer protamine sulfate
D. Continue the infusion and recheck the aPTT in 4 hours
Answer: B. Stop the heparin infusion. A therapeutic aPTT is typically 1.5
to 2.5 times the control, meaning a range of 45 to 75 seconds. A value
of 95 seconds indicates a critically high level, placing the client at
significant risk for bleeding. The infusion must be stopped immediately
and the healthcare provider notified. Protamine sulfate is reserved for
severe, active bleeding. Increasing the rate would exacerbate the risk.
3. A nurse is providing discharge instructions to a client with a new
prescription for warfarin. Which client statement indicates a need for
further teaching?
A. I will use an electric razor for shaving
B. I will keep my intake of green leafy vegetables consistent
C. I will take the medication with a large glass of grapefruit juice each
morning
D. I will report any signs of unusual bruising to my provider
Answer: C. I will take the medication with a large glass of grapefruit
juice each morning. Grapefruit juice inhibits the cytochrome P450
enzyme system, which can significantly increase the effect of warfarin
and the risk of bleeding. Consistent intake of vitamin K-rich foods is
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acceptable, but grapefruit juice should be avoided. Using an electric
razor and reporting bruising are appropriate safety measures.
4. A client is admitted with a serum calcium level of 7.0 mg/dL. Which
assessment finding is the nurse most likely to observe?
A. Positive Chvostek's sign
B. Profound muscle weakness
C. Diminished deep tendon reflexes
D. Prolonged QT interval on ECG
Answer: A. Positive Chvostek's sign. Hypocalcemia increases
neuromuscular excitability, leading to signs of tetany such as Chvostek's
sign (facial muscle contraction when tapping the facial nerve) and
Trousseau's sign. Muscle weakness and diminished reflexes are
associated with hypercalcemia. While hypocalcemia can prolong the QT
interval, Chvostek's sign is a more direct and specific bedside
assessment finding.
5. The nurse is auscultating the lungs of a client with left-sided heart
failure. Which breath sound should the nurse expect to hear?
A. Stridor
B. Rhonchi
C. Pleural friction rub
D. Crackles
Answer: D. Crackles. Left-sided heart failure causes increased pressure
in the pulmonary vasculature, forcing fluid into the alveoli. This
, 4|Page
manifests as crackles (rales) heard in the dependent portions of the
lungs due to fluid accumulation. Stridor is a sign of upper airway
obstruction, rhonchi are related to secretions in large airways, and a
pleural friction rub indicates pleural inflammation.
6. A nurse is caring for a client immediately following a cardiac
catheterization via the femoral artery. Which assessment finding
requires the most rapid action?
A. Pain at the insertion site rated 2 out of 10
B. A small hematoma at the puncture site
C. Absence of a pedal pulse on the affected extremity
D. Blood pressure of 130/84 mm Hg
Answer: C. Absence of a pedal pulse on the affected extremity. Loss of a
previously palpable distal pulse may indicate arterial occlusion, a
vascular emergency that can threaten limb viability and requires
immediate intervention. Pain and small hematomas are common and
require monitoring. A slightly elevated blood pressure is not an
immediate threat to the limb.
7. A client is receiving a blood transfusion and develops chills, fever,
and flank pain. What is the nurse's first action?
A. Slow the transfusion rate
B. Administer acetaminophen per protocol
C. Stop the transfusion immediately
D. Notify the blood bank
Saunders NCLEX-RN Test Bank Questions And Answers Practice
Exam 2026-2027 BANK QUESTIONS WITH DETAILED
VERIFIED ANSWERS EXAM QUESTIONS WILL COME
FROM HERE (100% CORRECT ANSWERS A+ GRADED
1. A nurse is caring for a client admitted with a diagnosis of acute
myocardial infarction. The client suddenly develops a loud holosystolic
murmur at the fifth intercostal space, midclavicular line. What
complication does the nurse suspect?
A. Pericarditis
B. Ventricular septal rupture
C. Mitral valve prolapse
D. Aortic stenosis
Answer: B. Ventricular septal rupture. A new loud holosystolic murmur
at the left sternal border following a myocardial infarction suggests a
rupture of the interventricular septum, a serious mechanical
complication that creates a left-to-right shunt. Pericarditis produces a
friction rub, not a holosystolic murmur. Mitral valve prolapse typically
presents with a mid-systolic click, and aortic stenosis produces a
systolic ejection murmur heard best at the right upper sternal border.
2. A client is receiving a continuous heparin infusion for a deep vein
thrombosis. The current activated partial thromboplastin time is 95
,2|Page
seconds, with a control value of 30 seconds. What is the priority nursing
action?
A. Increase the infusion rate per protocol
B. Stop the heparin infusion
C. Administer protamine sulfate
D. Continue the infusion and recheck the aPTT in 4 hours
Answer: B. Stop the heparin infusion. A therapeutic aPTT is typically 1.5
to 2.5 times the control, meaning a range of 45 to 75 seconds. A value
of 95 seconds indicates a critically high level, placing the client at
significant risk for bleeding. The infusion must be stopped immediately
and the healthcare provider notified. Protamine sulfate is reserved for
severe, active bleeding. Increasing the rate would exacerbate the risk.
3. A nurse is providing discharge instructions to a client with a new
prescription for warfarin. Which client statement indicates a need for
further teaching?
A. I will use an electric razor for shaving
B. I will keep my intake of green leafy vegetables consistent
C. I will take the medication with a large glass of grapefruit juice each
morning
D. I will report any signs of unusual bruising to my provider
Answer: C. I will take the medication with a large glass of grapefruit
juice each morning. Grapefruit juice inhibits the cytochrome P450
enzyme system, which can significantly increase the effect of warfarin
and the risk of bleeding. Consistent intake of vitamin K-rich foods is
,3|Page
acceptable, but grapefruit juice should be avoided. Using an electric
razor and reporting bruising are appropriate safety measures.
4. A client is admitted with a serum calcium level of 7.0 mg/dL. Which
assessment finding is the nurse most likely to observe?
A. Positive Chvostek's sign
B. Profound muscle weakness
C. Diminished deep tendon reflexes
D. Prolonged QT interval on ECG
Answer: A. Positive Chvostek's sign. Hypocalcemia increases
neuromuscular excitability, leading to signs of tetany such as Chvostek's
sign (facial muscle contraction when tapping the facial nerve) and
Trousseau's sign. Muscle weakness and diminished reflexes are
associated with hypercalcemia. While hypocalcemia can prolong the QT
interval, Chvostek's sign is a more direct and specific bedside
assessment finding.
5. The nurse is auscultating the lungs of a client with left-sided heart
failure. Which breath sound should the nurse expect to hear?
A. Stridor
B. Rhonchi
C. Pleural friction rub
D. Crackles
Answer: D. Crackles. Left-sided heart failure causes increased pressure
in the pulmonary vasculature, forcing fluid into the alveoli. This
, 4|Page
manifests as crackles (rales) heard in the dependent portions of the
lungs due to fluid accumulation. Stridor is a sign of upper airway
obstruction, rhonchi are related to secretions in large airways, and a
pleural friction rub indicates pleural inflammation.
6. A nurse is caring for a client immediately following a cardiac
catheterization via the femoral artery. Which assessment finding
requires the most rapid action?
A. Pain at the insertion site rated 2 out of 10
B. A small hematoma at the puncture site
C. Absence of a pedal pulse on the affected extremity
D. Blood pressure of 130/84 mm Hg
Answer: C. Absence of a pedal pulse on the affected extremity. Loss of a
previously palpable distal pulse may indicate arterial occlusion, a
vascular emergency that can threaten limb viability and requires
immediate intervention. Pain and small hematomas are common and
require monitoring. A slightly elevated blood pressure is not an
immediate threat to the limb.
7. A client is receiving a blood transfusion and develops chills, fever,
and flank pain. What is the nurse's first action?
A. Slow the transfusion rate
B. Administer acetaminophen per protocol
C. Stop the transfusion immediately
D. Notify the blood bank
