GUARANTEED PASS: Saunders NCLEX-RN® Review Test Bank (10th Ed.) – 1000+
Questions with Verified Answers & Rationales Ace the NCLEX-RN® with
Confidence!
Prepare for success with the complete set of 1000 high-quality, exam-style
multiplechoice questions designed to complement the Saunders Comprehensive Review
for the NCLEX-RN® Examination, 9th Edition by leading experts Linda Anne Silvestri &
Angela Silvestri.
This comprehensive Test Bank offers:
✅ Comprehensive Coverage: Master all core NCLEX-RN® content areas. ✅ Detailed
Rationales: Understand why each answer is correct with evidence-based explanations. ✅
Up-to-Date: Reflects the latest 2026 NCLEX-RN® test plan. ✅ Structured Study:
Easily organize your learning by topic, difficulty, and client needs categories. ✅ Ideal for
All: Perfect for individual preparation, study groups, and nursing program use. ✅
GUARANTEED PASS: Your trusted resource when used alongside the 10th Edition
Saunders Review.
1. A nurse is assigned to care for a client with chronic renal failure who is undergoing
hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which of the
following interventions should the nurse implement in caring for the client? Select all that apply.
A) Assessing the radial pulse in the right extremity B) Using the left arm to take blood pressure
readings C) Drawing predialysis blood specimens from the left arm D) Assessing the area over the
AV fistula for a bruit and thrill each shift E) Placing a pressure dressing over the site after each
dialysis treatment F) Administering intravenous (IV) fluids through the venous site of the AV fistula as
needed Answer(s): A, B, C, D Rationale: Several precautions must be observed to ensure the function
,of an internal AV fistula. The nurse assesses the fistula, and the distal portion of the extremity, for
adequate circulation; checks for a bruit and a thrill by means of auscultation or palpation over the
access site; monitors the radial pulse in the extremity; and avoids taking blood pressure readings or
drawing blood from the arm with the AV fistula. Venipuncture is avoided in the extremity bearing the
AV fistula. Blood is never drawn from the AV fistula, and the AV fistula is not used for the
administration of IV fluids. The AV fistula site is not covered with a pressure dressing after dialysis.
2. A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the
following outcomes does the nurse recognize as optimal respiratory outcomes for the client?
Select all that apply. A) Normal deep tendon reflexes B) Improved skeletal muscle tone C) Absence of
paresthesias in the lower extremities
D) Clear sounds in the lower lung fields bilaterally E) Po₂ of 85% and Pco₂ of 40 mm Hg
Answer(s): D, E Rationale: Satisfactory respiratory outcomes include clear breath sounds on
auscultation, clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood
gases. The ABG results listed here — a Po₂ of 85% and a Pco₂ of 40 mm Hg — are normal. The
presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in
the lower extremities reflect improvement in the symptoms associated with Guillain-Barré but are not
specific to a respiratory outcome.
3. A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and
is now attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes
the rhythm depicted in the image. Which of the following nursing actions should the nurse take?
(Rhythm is continuous up and down in pic) A) Calling the rapid response team B) Preparing the
client for cardioversion C) Asking the client to bear down and cough D) Preparing to administer
diltiazem (Cardiazem) Answer: A Rationale: This pattern indicates ventricular fibrillation (VF). Clients
who have sustained a myocardial infarction are at great risk for VF. With the onset of VF the client
feels faint, then immediately loses consciousness and becomes pulseless and apneic. There is no blood
pressure, and heart sounds are absent. The goals of treatment are to terminate VF promptly and convert
it to an organized rhythm. Because defibrillation is the immediate treatment, the nurse must call the
,rapid response team and initiate cardiopulmonary resuscitation. The client would not be able to bear
down or cough. Cardioversion is a synchronized countershock that may be performed in emergencies
for unstable ventricular or supraventricular tachyarrhythmias or electively for stable tachyarrhythmias
that are resistant to medical therapies such as the administration of diltiazem (Cardiazem).
4. A nurse developing a plan of care for a client with a spinal cord injury includes measures
to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions does the
nurse incorporate into the plan to prevent this complication? A) Keeping a fan running in the
client's room B) Keeping the linens wrinkle-free under the client C) Limiting bladder catheterization
to once every 12 hours D) Avoiding the administration of enemas and rectal suppositories Answer: B
Rationale: The most frequent causes of autonomic dysreflexia are a distended bladder and impacted
feces in the rectum. Straight catheterization should be performed every 4 to 6 hours, and the Foley
catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction
are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the
skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize risk in
these areas.
5. A nurse provides home care instructions to a client who has been fitted with a halo device to
treat a cervical fracture. Which statement by the client indicates the need for further instruction?
A) "I need to get more fluids and fiber into my diet." B) "I should cut my food into small pieces before I
eat." C) "I need to put powder under the vest twice a day to prevent sweating." D) "I have to check
the pin sites every day and watch for signs of infection." Answer: C Rationale: The client should
cleanse the skin under the lambs-wool liner each day to prevent rashes or sores. Powder or lotions
should be used only sparingly or not at all because they may cake, resulting in skin irritation. The client
should increase intake of fluid and fiber to help prevent constipation. Food should be cut into small
pieces to facilitate chewing and swallowing. The client should also use a straw for drinking. The pin
sites should be checked daily for signs of infection.
6. A nurse is caring for client with increased intracranial pressure (ICP). In which position
should the nurse maintain the client? A) Supine, with the head extended B) Side-lying, with the neck
, flexed C) Supine, with the head turned to the side D) Head midline and elevated 30 to 45 degrees
Answer: D Rationale: The client with increased ICP should be positioned with the head in a neutral
midline position. It is the responsibility of the nurse to ensure that all those delivering care to the client
maintain the proper positioning. The client should avoid flexing or extending the neck or turning the
neck side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positioning
promotes venous drainage from the cranium to keep ICP down.
7. A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse
should: A) Assess the clear fluid for protein B) Check the clear fluid for the presence of glucose C)
Place cotton balls or dry gauze loosely in the ears D) Use an otoscope to assess the tympanic membrane
for rupture Answer: B Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may
accompany basilar skull fracture. CSF can be distinguished from other body fluids because it will
separate into bloody and yellow concentric rings on dressing material, a phenomenon referred to as the
halo sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF indicates
a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze, or an otoscope into
the ear puts the client at risk for infection.
8. A nurse is caring for a client who has just undergone cardioversion. Which of the
following interventions is the nurse's priority after this procedure? A) Administering oxygen B)
Monitoring the blood pressure C) Administering antidysrhythmic medications D) Monitoring the
client's level of consciousness Answer: A Rationale: Nursing responsibilities after cardioversion
include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of
consciousness, and detection of dysrhythmias. The priority nursing intervention here is administering
oxygen.
9. A client with diabetes mellitus who is scheduled to have blood drawn for determination of
the glycosylated hemoglobin (HbA1C) level asks the nurse why the test is necessary if he is
performing blood glucose monitoring at home. The nurse tells the client that this test is used
specifically to: A) Detect diabetic complications B) Assess long-term glycemic control C) Determine
whether the client is at risk for hypoglycemia D) Determine whether the prescribed insulin dosage is
adequate Answer: B Rationale: The HbA1C reading provides an indication of glycemic control over
Questions with Verified Answers & Rationales Ace the NCLEX-RN® with
Confidence!
Prepare for success with the complete set of 1000 high-quality, exam-style
multiplechoice questions designed to complement the Saunders Comprehensive Review
for the NCLEX-RN® Examination, 9th Edition by leading experts Linda Anne Silvestri &
Angela Silvestri.
This comprehensive Test Bank offers:
✅ Comprehensive Coverage: Master all core NCLEX-RN® content areas. ✅ Detailed
Rationales: Understand why each answer is correct with evidence-based explanations. ✅
Up-to-Date: Reflects the latest 2026 NCLEX-RN® test plan. ✅ Structured Study:
Easily organize your learning by topic, difficulty, and client needs categories. ✅ Ideal for
All: Perfect for individual preparation, study groups, and nursing program use. ✅
GUARANTEED PASS: Your trusted resource when used alongside the 10th Edition
Saunders Review.
1. A nurse is assigned to care for a client with chronic renal failure who is undergoing
hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which of the
following interventions should the nurse implement in caring for the client? Select all that apply.
A) Assessing the radial pulse in the right extremity B) Using the left arm to take blood pressure
readings C) Drawing predialysis blood specimens from the left arm D) Assessing the area over the
AV fistula for a bruit and thrill each shift E) Placing a pressure dressing over the site after each
dialysis treatment F) Administering intravenous (IV) fluids through the venous site of the AV fistula as
needed Answer(s): A, B, C, D Rationale: Several precautions must be observed to ensure the function
,of an internal AV fistula. The nurse assesses the fistula, and the distal portion of the extremity, for
adequate circulation; checks for a bruit and a thrill by means of auscultation or palpation over the
access site; monitors the radial pulse in the extremity; and avoids taking blood pressure readings or
drawing blood from the arm with the AV fistula. Venipuncture is avoided in the extremity bearing the
AV fistula. Blood is never drawn from the AV fistula, and the AV fistula is not used for the
administration of IV fluids. The AV fistula site is not covered with a pressure dressing after dialysis.
2. A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the
following outcomes does the nurse recognize as optimal respiratory outcomes for the client?
Select all that apply. A) Normal deep tendon reflexes B) Improved skeletal muscle tone C) Absence of
paresthesias in the lower extremities
D) Clear sounds in the lower lung fields bilaterally E) Po₂ of 85% and Pco₂ of 40 mm Hg
Answer(s): D, E Rationale: Satisfactory respiratory outcomes include clear breath sounds on
auscultation, clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood
gases. The ABG results listed here — a Po₂ of 85% and a Pco₂ of 40 mm Hg — are normal. The
presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in
the lower extremities reflect improvement in the symptoms associated with Guillain-Barré but are not
specific to a respiratory outcome.
3. A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and
is now attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes
the rhythm depicted in the image. Which of the following nursing actions should the nurse take?
(Rhythm is continuous up and down in pic) A) Calling the rapid response team B) Preparing the
client for cardioversion C) Asking the client to bear down and cough D) Preparing to administer
diltiazem (Cardiazem) Answer: A Rationale: This pattern indicates ventricular fibrillation (VF). Clients
who have sustained a myocardial infarction are at great risk for VF. With the onset of VF the client
feels faint, then immediately loses consciousness and becomes pulseless and apneic. There is no blood
pressure, and heart sounds are absent. The goals of treatment are to terminate VF promptly and convert
it to an organized rhythm. Because defibrillation is the immediate treatment, the nurse must call the
,rapid response team and initiate cardiopulmonary resuscitation. The client would not be able to bear
down or cough. Cardioversion is a synchronized countershock that may be performed in emergencies
for unstable ventricular or supraventricular tachyarrhythmias or electively for stable tachyarrhythmias
that are resistant to medical therapies such as the administration of diltiazem (Cardiazem).
4. A nurse developing a plan of care for a client with a spinal cord injury includes measures
to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions does the
nurse incorporate into the plan to prevent this complication? A) Keeping a fan running in the
client's room B) Keeping the linens wrinkle-free under the client C) Limiting bladder catheterization
to once every 12 hours D) Avoiding the administration of enemas and rectal suppositories Answer: B
Rationale: The most frequent causes of autonomic dysreflexia are a distended bladder and impacted
feces in the rectum. Straight catheterization should be performed every 4 to 6 hours, and the Foley
catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction
are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the
skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize risk in
these areas.
5. A nurse provides home care instructions to a client who has been fitted with a halo device to
treat a cervical fracture. Which statement by the client indicates the need for further instruction?
A) "I need to get more fluids and fiber into my diet." B) "I should cut my food into small pieces before I
eat." C) "I need to put powder under the vest twice a day to prevent sweating." D) "I have to check
the pin sites every day and watch for signs of infection." Answer: C Rationale: The client should
cleanse the skin under the lambs-wool liner each day to prevent rashes or sores. Powder or lotions
should be used only sparingly or not at all because they may cake, resulting in skin irritation. The client
should increase intake of fluid and fiber to help prevent constipation. Food should be cut into small
pieces to facilitate chewing and swallowing. The client should also use a straw for drinking. The pin
sites should be checked daily for signs of infection.
6. A nurse is caring for client with increased intracranial pressure (ICP). In which position
should the nurse maintain the client? A) Supine, with the head extended B) Side-lying, with the neck
, flexed C) Supine, with the head turned to the side D) Head midline and elevated 30 to 45 degrees
Answer: D Rationale: The client with increased ICP should be positioned with the head in a neutral
midline position. It is the responsibility of the nurse to ensure that all those delivering care to the client
maintain the proper positioning. The client should avoid flexing or extending the neck or turning the
neck side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positioning
promotes venous drainage from the cranium to keep ICP down.
7. A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse
should: A) Assess the clear fluid for protein B) Check the clear fluid for the presence of glucose C)
Place cotton balls or dry gauze loosely in the ears D) Use an otoscope to assess the tympanic membrane
for rupture Answer: B Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may
accompany basilar skull fracture. CSF can be distinguished from other body fluids because it will
separate into bloody and yellow concentric rings on dressing material, a phenomenon referred to as the
halo sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF indicates
a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze, or an otoscope into
the ear puts the client at risk for infection.
8. A nurse is caring for a client who has just undergone cardioversion. Which of the
following interventions is the nurse's priority after this procedure? A) Administering oxygen B)
Monitoring the blood pressure C) Administering antidysrhythmic medications D) Monitoring the
client's level of consciousness Answer: A Rationale: Nursing responsibilities after cardioversion
include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of
consciousness, and detection of dysrhythmias. The priority nursing intervention here is administering
oxygen.
9. A client with diabetes mellitus who is scheduled to have blood drawn for determination of
the glycosylated hemoglobin (HbA1C) level asks the nurse why the test is necessary if he is
performing blood glucose monitoring at home. The nurse tells the client that this test is used
specifically to: A) Detect diabetic complications B) Assess long-term glycemic control C) Determine
whether the client is at risk for hypoglycemia D) Determine whether the prescribed insulin dosage is
adequate Answer: B Rationale: The HbA1C reading provides an indication of glycemic control over
