SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE .doc
ANSWERED 100%
1) A child with an autism spectrum disorder (ASD) is being
admitted to the hospital for diagnostic tests. Which room
assignment is the most appropriate for the child?
✓ Private room
2) The labor and delivery room nurse has just received reports
on 4 clients. After reviewing the client data, the nurse
should assess which client first?
✓ A client who has just received an intravenous
loading dose of magnesium sulfate to stop preterm
labor
3) The nurse has developed a teaching plan for a client with
hypertension regarding the administration of prescribed
medications. What is the initial nursing action?
✓ Assess the client's readiness to learn.
4) A client with cancer is receiving intravenous morphine
sulfate for pain. When writing the plan of care for this
client, the nurse should include which action as the
priority action?
✓ Monitor respiratory status.
5) The nurse is preparing to suction the airway of a client who
has a tracheostomy tube and gathers the supplies needed for
the procedure. In order of priority, which actions should
the nurse take to perform this procedure? Arrange the
actions in the order that they should be performed. All
options must be used.
✓ 1) Place the client in a semi Fowler's
position.
✓ 2) Turn on the suction device and set the
regulator at 80 mm Hg.
✓ 3) Attach the suction tubing to the suction
catheter.
✓ 4) Hyperoxygenate the client.
✓ 5) Insert the catheter into the tracheostomy
until resistance is met, and then pull it back 1
cm.
, ✓ 6) Apply intermittent suction and slowly
withdraw the catheter while rotating it back and
forth.
6) The nurse notes blanching, coolness, and edema at a client's
peripheral intravenous (IV) site. Which nursing action is
the priority?
✓ Remove the IV catheter.
7) A client has a prescription to begin an infusion of 1000 mL
of 5% dextrose in lactated Ringer's solution. The client has
an intravenous (IV) cannula inserted, and the nurse prepares
the solution and IV tubing. Arrange the actions in the order
that they should be performed. All options must be used.
✓ 1) Close the roller clamp on the IV tubing.
✓ 2) Spike the IV bag and half-fill the drip
chamber.
✓ 3) Open the roller clamp and fill the tubing.
✓ 4) Uncap the distal end of the tubing.
✓ 5) Attach the distal end of the tubing to the
client.
8) The nurse is caring for 4 pediatric clients. After receiving
reports from the night shift, which child should the nurse
assess first?
✓ A 6-week-old infant admitted to the hospital
for decreased level of consciousness; shaken baby
syndrome is suspected
9) The nurse is assigned to 4 clients on a postoperative
surgical unit at a rural hospital. When prioritizing the
care, the nurse recognizes that the highest priority is
focused on which client?
✓ The client with problems clearing the airway
related to abdominal incision pain
10) The emergency department nurse is caring for a chi ld
with suspected epiglottitis and has ensured that the child
has a patent airway. Which action is the next priority in
the care of this child?
✓ Prepare the child for a chest radiograph.
,11) The nursing instructor asks the nursing student to
identify the priorities of care for an assigned client. The
nursing instructor determines that the nursing student
understands the client's needs when which statement is made?
✓ "Actual or life-threatening concerns are the
priority."
12) A hospitalized client with type 1 diabetes mellitus
received Humulin N and Humulin R insulin 2 hours ago (at
7:30 a.m.). The client calls the nurse and reports that he
is feeling hungry, shaky, and weak. The client ate breakfast
at 8 a.m. and is due to eat lunch at noon. Arrange the
actions that the nurse will take in the order that they
should be performed. All options must be used.
✓ 1) Check the client's blood glucose level.
✓ 2) Give the client ½ cup (118 mL) of fruit
juice to drink.
✓ 3) Take the client's vital signs.
✓ 4) Retest the blood glucose level.
✓ 5) Give the client a small snack of
carbohydrate and protein.
✓ 6) Document the client's complaints, actions
taken, and outcome.
13) An emergency department nurse is preparing to receive 4
clients as a result of a motor vehicle crash. Which victim
should the nurse attend to first?
✓ A 45-year-old man with chest pain, shortness
of breath, and diaphoresis
14) The nurse is assigned to care for 4 clients. Which
client should the nurse assess first?
✓ A client who has a peripheral (index finger)
oxygen saturation percentage of 85%
15) The nurse has received her client assignment for the
day. Which client should the nurse care for first?
✓ A client with postoperative pain reported at
7 out of 10, with 10 being the worst
, 16) The nurse has received the client assignment for the
day. Which client should the nurse care for first?
✓ The client admitted with the medical
diagnosis of neutropenia who is afebrile and is
complaining of pain with urination
17) The nurse is the first responder at the scene of a 6-
car crash on a highway. Which victim should the nurse attend
to first?
✓ A victim experiencing dyspnea
18) The nurse in charge of a nursing unit is asked to
select the hospitalized clients who can be discharg ed so
that hospital beds can be made available for victims of a
community disaster. Which clients can be safely discharged?
Select all that apply.
✓ A client with a Holter monitor
✓ A client receiving oral antibiotics
✓ A client experiencing sinus rhythm
19) The nurse has received her client assignment for the
day. Which client should the nurse check first?
✓ A client who has just returned from surgery
20) The nurse is a responder at the scene of a building
collapse. Which victim should the nurse care for first?
✓ Victim with an apparent chest wall defect and
asymmetrical chest wall movement
21) The nurse manager of a medical-surgical unit is asked
to select the hospitalized clients who can be discharged so
that hospital beds can be made available for victims of a
community disaster. Which clients can be safely discharged?
Select all that apply.
✓ Client postoperative day 1 after inguinal
herniorrhaphy, vital signs stable
✓ Client 5 days after a myocardial infarction,
vital signs stable, absence of dysrhythmias
✓ Client 1 day after cardiac catheterization,
normal study results, groin site free of hematoma
ANSWERED 100%
1) A child with an autism spectrum disorder (ASD) is being
admitted to the hospital for diagnostic tests. Which room
assignment is the most appropriate for the child?
✓ Private room
2) The labor and delivery room nurse has just received reports
on 4 clients. After reviewing the client data, the nurse
should assess which client first?
✓ A client who has just received an intravenous
loading dose of magnesium sulfate to stop preterm
labor
3) The nurse has developed a teaching plan for a client with
hypertension regarding the administration of prescribed
medications. What is the initial nursing action?
✓ Assess the client's readiness to learn.
4) A client with cancer is receiving intravenous morphine
sulfate for pain. When writing the plan of care for this
client, the nurse should include which action as the
priority action?
✓ Monitor respiratory status.
5) The nurse is preparing to suction the airway of a client who
has a tracheostomy tube and gathers the supplies needed for
the procedure. In order of priority, which actions should
the nurse take to perform this procedure? Arrange the
actions in the order that they should be performed. All
options must be used.
✓ 1) Place the client in a semi Fowler's
position.
✓ 2) Turn on the suction device and set the
regulator at 80 mm Hg.
✓ 3) Attach the suction tubing to the suction
catheter.
✓ 4) Hyperoxygenate the client.
✓ 5) Insert the catheter into the tracheostomy
until resistance is met, and then pull it back 1
cm.
, ✓ 6) Apply intermittent suction and slowly
withdraw the catheter while rotating it back and
forth.
6) The nurse notes blanching, coolness, and edema at a client's
peripheral intravenous (IV) site. Which nursing action is
the priority?
✓ Remove the IV catheter.
7) A client has a prescription to begin an infusion of 1000 mL
of 5% dextrose in lactated Ringer's solution. The client has
an intravenous (IV) cannula inserted, and the nurse prepares
the solution and IV tubing. Arrange the actions in the order
that they should be performed. All options must be used.
✓ 1) Close the roller clamp on the IV tubing.
✓ 2) Spike the IV bag and half-fill the drip
chamber.
✓ 3) Open the roller clamp and fill the tubing.
✓ 4) Uncap the distal end of the tubing.
✓ 5) Attach the distal end of the tubing to the
client.
8) The nurse is caring for 4 pediatric clients. After receiving
reports from the night shift, which child should the nurse
assess first?
✓ A 6-week-old infant admitted to the hospital
for decreased level of consciousness; shaken baby
syndrome is suspected
9) The nurse is assigned to 4 clients on a postoperative
surgical unit at a rural hospital. When prioritizing the
care, the nurse recognizes that the highest priority is
focused on which client?
✓ The client with problems clearing the airway
related to abdominal incision pain
10) The emergency department nurse is caring for a chi ld
with suspected epiglottitis and has ensured that the child
has a patent airway. Which action is the next priority in
the care of this child?
✓ Prepare the child for a chest radiograph.
,11) The nursing instructor asks the nursing student to
identify the priorities of care for an assigned client. The
nursing instructor determines that the nursing student
understands the client's needs when which statement is made?
✓ "Actual or life-threatening concerns are the
priority."
12) A hospitalized client with type 1 diabetes mellitus
received Humulin N and Humulin R insulin 2 hours ago (at
7:30 a.m.). The client calls the nurse and reports that he
is feeling hungry, shaky, and weak. The client ate breakfast
at 8 a.m. and is due to eat lunch at noon. Arrange the
actions that the nurse will take in the order that they
should be performed. All options must be used.
✓ 1) Check the client's blood glucose level.
✓ 2) Give the client ½ cup (118 mL) of fruit
juice to drink.
✓ 3) Take the client's vital signs.
✓ 4) Retest the blood glucose level.
✓ 5) Give the client a small snack of
carbohydrate and protein.
✓ 6) Document the client's complaints, actions
taken, and outcome.
13) An emergency department nurse is preparing to receive 4
clients as a result of a motor vehicle crash. Which victim
should the nurse attend to first?
✓ A 45-year-old man with chest pain, shortness
of breath, and diaphoresis
14) The nurse is assigned to care for 4 clients. Which
client should the nurse assess first?
✓ A client who has a peripheral (index finger)
oxygen saturation percentage of 85%
15) The nurse has received her client assignment for the
day. Which client should the nurse care for first?
✓ A client with postoperative pain reported at
7 out of 10, with 10 being the worst
, 16) The nurse has received the client assignment for the
day. Which client should the nurse care for first?
✓ The client admitted with the medical
diagnosis of neutropenia who is afebrile and is
complaining of pain with urination
17) The nurse is the first responder at the scene of a 6-
car crash on a highway. Which victim should the nurse attend
to first?
✓ A victim experiencing dyspnea
18) The nurse in charge of a nursing unit is asked to
select the hospitalized clients who can be discharg ed so
that hospital beds can be made available for victims of a
community disaster. Which clients can be safely discharged?
Select all that apply.
✓ A client with a Holter monitor
✓ A client receiving oral antibiotics
✓ A client experiencing sinus rhythm
19) The nurse has received her client assignment for the
day. Which client should the nurse check first?
✓ A client who has just returned from surgery
20) The nurse is a responder at the scene of a building
collapse. Which victim should the nurse care for first?
✓ Victim with an apparent chest wall defect and
asymmetrical chest wall movement
21) The nurse manager of a medical-surgical unit is asked
to select the hospitalized clients who can be discharged so
that hospital beds can be made available for victims of a
community disaster. Which clients can be safely discharged?
Select all that apply.
✓ Client postoperative day 1 after inguinal
herniorrhaphy, vital signs stable
✓ Client 5 days after a myocardial infarction,
vital signs stable, absence of dysrhythmias
✓ Client 1 day after cardiac catheterization,
normal study results, groin site free of hematoma
