NURSING
SAUNDERS Med Surg 2SAUNDERS
COMPREHENSIVE COMPREHENSIVE
REVIEW FOR NCLEX REVIEW
FIVE . FOR NCLEX FIVE .
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.
,NURSING
SAUNDERSMed Surg 2SAUNDERS
COMPREHENSIVE COMPREHENSIVE
REVIEW FOR NCLEX REVIEW
FIVE . FOR NCLEX FIVE .
✓ 4) Hyperoxygenate the client.
✓ 5) Insert the catheter into the
tracheostomy until resistance is met, and then
pull it back 1 cm.
,NURSING
SAUNDERSMed Surg 2SAUNDERS
COMPREHENSIVE COMPREHENSIVE
REVIEW FOR NCLEX REVIEW
FIVE . FOR NCLEX FIVE .
✓ 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 child
with suspected epiglottitis and has ensured that the child
, NURSING
SAUNDERSMed Surg 2SAUNDERS
COMPREHENSIVE COMPREHENSIVE
REVIEW FOR NCLEX REVIEW
FIVE . FOR NCLEX FIVE .
has a patent airway. Which action is the next priority in
the care of this child?
✓ Prepare the child for a chest radiograph.
SAUNDERS Med Surg 2SAUNDERS
COMPREHENSIVE COMPREHENSIVE
REVIEW FOR NCLEX REVIEW
FIVE . FOR NCLEX FIVE .
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.
,NURSING
SAUNDERSMed Surg 2SAUNDERS
COMPREHENSIVE COMPREHENSIVE
REVIEW FOR NCLEX REVIEW
FIVE . FOR NCLEX FIVE .
✓ 4) Hyperoxygenate the client.
✓ 5) Insert the catheter into the
tracheostomy until resistance is met, and then
pull it back 1 cm.
,NURSING
SAUNDERSMed Surg 2SAUNDERS
COMPREHENSIVE COMPREHENSIVE
REVIEW FOR NCLEX REVIEW
FIVE . FOR NCLEX FIVE .
✓ 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 child
with suspected epiglottitis and has ensured that the child
, NURSING
SAUNDERSMed Surg 2SAUNDERS
COMPREHENSIVE COMPREHENSIVE
REVIEW FOR NCLEX REVIEW
FIVE . FOR NCLEX FIVE .
has a patent airway. Which action is the next priority in
the care of this child?
✓ Prepare the child for a chest radiograph.
