SAUNDERS NCLEX-RN REVIEW
EXAMINATION WITH ANSWERS &
DETAILED RATIONALES NEW
LATEST EXAM UPDATE
Safe and Effective Care Environment
(Management of Care, Safety, Infection Control)
1. The nurse is assigning tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
• A. Ambulating a client who is 1-day post-operative following a hernia repair.
• B. Assessing the lung sounds of a client with pneumonia.
• C. Developing the plan of care for a client with a new colostomy.
• D. Teaching a family member how to perform passive range of motion exercises.
o Answer: A. Ambulating a client who is 1-day post-operative following a hernia repair.
o Rationale: Delegation is based on predictability of outcome and stability of the client.
Ambulating a stable post-op client is a routine task within the UAP's scope. Assessment (B), care
planning (C), and initial teaching (D) require the critical thinking and education of the licensed
nurse. (Management of Care)
2. A nurse discovers a client on the floor. The client states, "I'm so clumsy, I just tripped
over the bathroom mat." What is the nurse's priority action?
Page 1 of 49
,• A. Complete an incident report.
• B. Check the client for injuries.
• C. Move the client back to bed. D. Place a fall risk sign on the door.
o Answer: B. Check the client for injuries.
o Rationale: Client assessment and stabilization are always the first priority. The nurse must assess
for any injuries (fracture, laceration, head injury) before moving the client or leaving to complete
paperwork. (Management of Care)
3. Which action by a nurse demonstrates adherence to the principle of informed consent?
• A. Explaining the risks and benefits of a surgical procedure to the client.
• B. Serving as a witness to the client's signature on the consent form.
• C. Telling the client that the doctor will be in shortly to explain the procedure. D.
Answering the client's questions about what the recovery will be like.
o Answer: B. Serving as a witness to the client's signature on the consent form. o Rationale: The
nurse's role in the informed consent process is to witness the signature, ensure the client appears
competent to sign, and that the consent was given voluntarily. It is the responsibility of the provider
performing the procedure to explain the risks, benefits, and alternatives. (Management of Care)
4. A nurse is preparing to administer a tuberculosis (TB) skin test. Which personal
protective equipment (PPE) is required?
• A. N95 respirator mask.
• B. Gown and gloves.
• C. Surgical mask. D. Gloves only.
o Answer: D. Gloves only.
o *Rationale: Standard precautions apply. A TB skin test is an intradermal injection with minimal
risk of exposure to blood or body fluids. Gloves are worn for potential contact with blood.
Airborne precautions (N95 mask) are required when entering the room of a client with suspected
or confirmed active pulmonary TB, but not for administering a skin test to a non-infectious client.
(Safety and Infection Control)*
, 10. The nurse is caring for a client with Clostridium difficile (C. diff) infection. Which hand
hygiene method is correct?
• A. Clean hands with an alcohol-based hand rub before and after entering the room.
• B. Wash hands with soap and water after caring for the client.
• C. Use alcohol-based hand rub only if hands are not visibly soiled. D. Wear gloves, so hand
hygiene is not necessary.
o Answer: B. Wash hands with soap and water after caring for the client.
o Rationale: C. diff spores are not killed by alcohol-based hand rubs. Mechanical friction and
running water are required to remove the spores from the hands. Handwashing with soap and
water is the mandatory method when caring for clients with C. diff. (Safety and Infection
Control)
5. A charge nurse is making client assignments on a medical-surgical unit. Which client
should be assigned to the most experienced registered nurse (RN)?
• A. A 45-year-old with type 2 diabetes requiring a dressing change for a foot ulcer.
• B. A 60-year-old 2 days post-operative following a total knee replacement who is using a patient-
controlled analgesia (PCA) pump.
• C. A 55-year-old newly admitted with unstable vital signs and gastrointestinal bleeding.
• D. A 30-year-old with pneumonia receiving IV antibiotics every 8 hours.
o Answer: C. A 55-year-old newly admitted with unstable vital signs and gastrointestinal
bleeding.
o Rationale: Client acuity and stability determine assignment. The unstable client (C) requires the
most experienced nurse due to the potential for rapid decompensation and need for complex
assessment. The other clients are stable, have predictable outcomes, and are appropriate for
newer staff. (Management of Care)
o Priority Nursing Tip: When assigning staff, match the client's acuity and care needs to the staff
member's competency and scope of practice.
Page 3 of 49
, 6. A nurse enters a client's room and finds smoke coming from the electrical outlet near the
bed. Place the following actions in the order they should be performed (Drag and
Drop/Ordered Response).
1. Evacuate the client from the room.
2. Pull the fire alarm.
3. Close the client's door.
4. Attempt to extinguish the fire with an extinguisher.
• Answer: 1, 2, 3, 4
• Rationale: The correct order follows the RACE acronym: Rescue (remove the client), Alarm
(activate the alarm), Contain (close doors), and Extinguish. Rescue is always the first priority.
(Safety and Infection Control)
7. A nurse is providing discharge teaching to a client with a new diagnosis of HIV. Which
statement by the client indicates a need for further teaching regarding infection control at
home?
• A. "I will clean up any blood spills with a bleach and water solution."
• B. "I need to wash my hands before and after preparing food."
• C. "I should put my used tissues in a separate bag from the household trash." D. "I can
share dishes and utensils as long as they are washed in hot, soapy water." o Answer: C. "I should
put my used tissues in a separate bag from the household trash."
o Rationale: Standard precautions are used at home. Tissues and other articles soiled with secretions
that are not grossly contaminated with blood do not require special handling or double-bagging;
they can be placed in the regular trash. Handwashing and cleaning blood spills with bleach are
correct. Dishes do not require special separation. (Safety and Infection Control)
8. The nurse manager is reviewing a medication error report. Which action by a staff nurse
represents a sentinel event?
• A. Administering digoxin to the wrong client, who then experiences cardiac arrest.
• B. Omitting the morning dose of a client's antihypertensive medication.
EXAMINATION WITH ANSWERS &
DETAILED RATIONALES NEW
LATEST EXAM UPDATE
Safe and Effective Care Environment
(Management of Care, Safety, Infection Control)
1. The nurse is assigning tasks to an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
• A. Ambulating a client who is 1-day post-operative following a hernia repair.
• B. Assessing the lung sounds of a client with pneumonia.
• C. Developing the plan of care for a client with a new colostomy.
• D. Teaching a family member how to perform passive range of motion exercises.
o Answer: A. Ambulating a client who is 1-day post-operative following a hernia repair.
o Rationale: Delegation is based on predictability of outcome and stability of the client.
Ambulating a stable post-op client is a routine task within the UAP's scope. Assessment (B), care
planning (C), and initial teaching (D) require the critical thinking and education of the licensed
nurse. (Management of Care)
2. A nurse discovers a client on the floor. The client states, "I'm so clumsy, I just tripped
over the bathroom mat." What is the nurse's priority action?
Page 1 of 49
,• A. Complete an incident report.
• B. Check the client for injuries.
• C. Move the client back to bed. D. Place a fall risk sign on the door.
o Answer: B. Check the client for injuries.
o Rationale: Client assessment and stabilization are always the first priority. The nurse must assess
for any injuries (fracture, laceration, head injury) before moving the client or leaving to complete
paperwork. (Management of Care)
3. Which action by a nurse demonstrates adherence to the principle of informed consent?
• A. Explaining the risks and benefits of a surgical procedure to the client.
• B. Serving as a witness to the client's signature on the consent form.
• C. Telling the client that the doctor will be in shortly to explain the procedure. D.
Answering the client's questions about what the recovery will be like.
o Answer: B. Serving as a witness to the client's signature on the consent form. o Rationale: The
nurse's role in the informed consent process is to witness the signature, ensure the client appears
competent to sign, and that the consent was given voluntarily. It is the responsibility of the provider
performing the procedure to explain the risks, benefits, and alternatives. (Management of Care)
4. A nurse is preparing to administer a tuberculosis (TB) skin test. Which personal
protective equipment (PPE) is required?
• A. N95 respirator mask.
• B. Gown and gloves.
• C. Surgical mask. D. Gloves only.
o Answer: D. Gloves only.
o *Rationale: Standard precautions apply. A TB skin test is an intradermal injection with minimal
risk of exposure to blood or body fluids. Gloves are worn for potential contact with blood.
Airborne precautions (N95 mask) are required when entering the room of a client with suspected
or confirmed active pulmonary TB, but not for administering a skin test to a non-infectious client.
(Safety and Infection Control)*
, 10. The nurse is caring for a client with Clostridium difficile (C. diff) infection. Which hand
hygiene method is correct?
• A. Clean hands with an alcohol-based hand rub before and after entering the room.
• B. Wash hands with soap and water after caring for the client.
• C. Use alcohol-based hand rub only if hands are not visibly soiled. D. Wear gloves, so hand
hygiene is not necessary.
o Answer: B. Wash hands with soap and water after caring for the client.
o Rationale: C. diff spores are not killed by alcohol-based hand rubs. Mechanical friction and
running water are required to remove the spores from the hands. Handwashing with soap and
water is the mandatory method when caring for clients with C. diff. (Safety and Infection
Control)
5. A charge nurse is making client assignments on a medical-surgical unit. Which client
should be assigned to the most experienced registered nurse (RN)?
• A. A 45-year-old with type 2 diabetes requiring a dressing change for a foot ulcer.
• B. A 60-year-old 2 days post-operative following a total knee replacement who is using a patient-
controlled analgesia (PCA) pump.
• C. A 55-year-old newly admitted with unstable vital signs and gastrointestinal bleeding.
• D. A 30-year-old with pneumonia receiving IV antibiotics every 8 hours.
o Answer: C. A 55-year-old newly admitted with unstable vital signs and gastrointestinal
bleeding.
o Rationale: Client acuity and stability determine assignment. The unstable client (C) requires the
most experienced nurse due to the potential for rapid decompensation and need for complex
assessment. The other clients are stable, have predictable outcomes, and are appropriate for
newer staff. (Management of Care)
o Priority Nursing Tip: When assigning staff, match the client's acuity and care needs to the staff
member's competency and scope of practice.
Page 3 of 49
, 6. A nurse enters a client's room and finds smoke coming from the electrical outlet near the
bed. Place the following actions in the order they should be performed (Drag and
Drop/Ordered Response).
1. Evacuate the client from the room.
2. Pull the fire alarm.
3. Close the client's door.
4. Attempt to extinguish the fire with an extinguisher.
• Answer: 1, 2, 3, 4
• Rationale: The correct order follows the RACE acronym: Rescue (remove the client), Alarm
(activate the alarm), Contain (close doors), and Extinguish. Rescue is always the first priority.
(Safety and Infection Control)
7. A nurse is providing discharge teaching to a client with a new diagnosis of HIV. Which
statement by the client indicates a need for further teaching regarding infection control at
home?
• A. "I will clean up any blood spills with a bleach and water solution."
• B. "I need to wash my hands before and after preparing food."
• C. "I should put my used tissues in a separate bag from the household trash." D. "I can
share dishes and utensils as long as they are washed in hot, soapy water." o Answer: C. "I should
put my used tissues in a separate bag from the household trash."
o Rationale: Standard precautions are used at home. Tissues and other articles soiled with secretions
that are not grossly contaminated with blood do not require special handling or double-bagging;
they can be placed in the regular trash. Handwashing and cleaning blood spills with bleach are
correct. Dishes do not require special separation. (Safety and Infection Control)
8. The nurse manager is reviewing a medication error report. Which action by a staff nurse
represents a sentinel event?
• A. Administering digoxin to the wrong client, who then experiences cardiac arrest.
• B. Omitting the morning dose of a client's antihypertensive medication.
