SA
SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE
1) A child with an autism spectrum disorder (ASD) is being admitted to the hospital for
diagnostic tests. Which roomassignment is the most appropriate for the child?
✓ Private room
2) The labor and delivery room nurse has just received reportson 4 clients. After reviewing
the client data, the nurse should assess which client first?
✓ A client who has just received an intravenousloading dose of
magnesium sulfate to stop preterm labor
3) The nurse has developed a teaching plan for a client withhypertension 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 thisclient, 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 whohas 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'sposition.
✓ 2)Turn on the suction device and set theregulator at 80 mm
Hg.
✓ 3)Attach the suction tubing to the suctioncatheter.
✓ 4)Hyperoxygenate the client.
✓ 5) Insert the catheter into the tracheostomyuntil resistance is met,
and then pull it back 1cm.
,SA
✓ 6) Apply intermittent suction and slowly withdraw the catheter
while rotating it back andforth.
6) The nurse notes blanching, coolness, and edema at a client'speripheral 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 hasan intravenous (IV) cannula inserted, and the nurse
preparesthe solution and IV tubing. Arrange the actions in the orderthat 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 dripchamber.
✓ 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 theclient.
8) The nurse is caring for 4 pediatric clients. After receivingreports from the night shift,
which child should the nurse assess first?
✓ A 6-week-old infant admitted to the hospitalfor decreased level of
consciousness; shaken babysyndrome is suspected
9) The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital.
When prioritizing thecare, the nurse recognizes that the highest priority is focused
on which client?
✓ The client with problems clearing the airwayrelated to abdominal
incision pain
10) The emergency department nurse is caring for a childwith suspected epiglottitis
and has ensured that the childhas a patent airway. Which action is the next priority in
the care of this child?
✓ Prepare the child for a chest radiograph.
,SA
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 thepriority."
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 breakfastat 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 fruitjuice to drink.
✓ 3)Take the client's vital signs.
✓ 4)Retest the blood glucose level.
✓ 5)Give the client a small snack ofcarbohydrate and
protein.
✓ 6)Document the client's complaints, actionstaken, and outcome.
13) An emergency department nurse is preparing to receive 4clients as a result of a
motor vehicle crash. Which victim should the nurse attend to first?
✓ A 45-year-old man with chest pain, shortnessof breath, and
diaphoresis
14) The nurse is assigned to care for 4 clients. Whichclient 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 theday. Which client should
the nurse care for first?
✓ A client with postoperative pain reported at
7 out of 10, with 10 being the worst
, SA
16) The nurse has received the client assignment for theday. Which client should
the nurse care for first?
✓ The client admitted with the medical diagnosis of neutropenia
who is afebrile and iscomplaining 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 attendto first?
✓ A victim experiencing dyspnea
18) The nurse in charge of a nursing 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.
✓ 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 theday. 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 buildingcollapse. Which victim
should the nurse care for first?
✓ Victim with an apparent chest wall defect andasymmetrical chest
wall movement
21) The nurse manager of a medical-surgical unit is askedto select the hospitalized
clients who can be discharged sothat 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 inguinalherniorrhaphy, 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
SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE
1) A child with an autism spectrum disorder (ASD) is being admitted to the hospital for
diagnostic tests. Which roomassignment is the most appropriate for the child?
✓ Private room
2) The labor and delivery room nurse has just received reportson 4 clients. After reviewing
the client data, the nurse should assess which client first?
✓ A client who has just received an intravenousloading dose of
magnesium sulfate to stop preterm labor
3) The nurse has developed a teaching plan for a client withhypertension 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 thisclient, 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 whohas 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'sposition.
✓ 2)Turn on the suction device and set theregulator at 80 mm
Hg.
✓ 3)Attach the suction tubing to the suctioncatheter.
✓ 4)Hyperoxygenate the client.
✓ 5) Insert the catheter into the tracheostomyuntil resistance is met,
and then pull it back 1cm.
,SA
✓ 6) Apply intermittent suction and slowly withdraw the catheter
while rotating it back andforth.
6) The nurse notes blanching, coolness, and edema at a client'speripheral 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 hasan intravenous (IV) cannula inserted, and the nurse
preparesthe solution and IV tubing. Arrange the actions in the orderthat 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 dripchamber.
✓ 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 theclient.
8) The nurse is caring for 4 pediatric clients. After receivingreports from the night shift,
which child should the nurse assess first?
✓ A 6-week-old infant admitted to the hospitalfor decreased level of
consciousness; shaken babysyndrome is suspected
9) The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital.
When prioritizing thecare, the nurse recognizes that the highest priority is focused
on which client?
✓ The client with problems clearing the airwayrelated to abdominal
incision pain
10) The emergency department nurse is caring for a childwith suspected epiglottitis
and has ensured that the childhas a patent airway. Which action is the next priority in
the care of this child?
✓ Prepare the child for a chest radiograph.
,SA
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 thepriority."
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 breakfastat 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 fruitjuice to drink.
✓ 3)Take the client's vital signs.
✓ 4)Retest the blood glucose level.
✓ 5)Give the client a small snack ofcarbohydrate and
protein.
✓ 6)Document the client's complaints, actionstaken, and outcome.
13) An emergency department nurse is preparing to receive 4clients as a result of a
motor vehicle crash. Which victim should the nurse attend to first?
✓ A 45-year-old man with chest pain, shortnessof breath, and
diaphoresis
14) The nurse is assigned to care for 4 clients. Whichclient 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 theday. Which client should
the nurse care for first?
✓ A client with postoperative pain reported at
7 out of 10, with 10 being the worst
, SA
16) The nurse has received the client assignment for theday. Which client should
the nurse care for first?
✓ The client admitted with the medical diagnosis of neutropenia
who is afebrile and iscomplaining 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 attendto first?
✓ A victim experiencing dyspnea
18) The nurse in charge of a nursing 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.
✓ 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 theday. 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 buildingcollapse. Which victim
should the nurse care for first?
✓ Victim with an apparent chest wall defect andasymmetrical chest
wall movement
21) The nurse manager of a medical-surgical unit is askedto select the hospitalized
clients who can be discharged sothat 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 inguinalherniorrhaphy, 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
