SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR
1) The nurse would anticipate that the health care provider
(HCP) would add which medication to the regimen of the
client receiving isoniazid?
✓ Pyridoxine
2) A postpartum nurse is caring for a client with an epidural
catheter in place for opioid analgesic administration
following cesarean birth. The client develops respiratory
depression and requires naloxone administration. Which
finding should the nurse anticipate as a result of the
naloxone administration?
✓ Increase in pain level
3) The nurse should monitor the client receiving the first dose
of albuterol for which side or adverse effect of this
medication?
✓ Tachycardia
4) The client has a prescription to receive pirbuterol 2 puffs
and beclomethasone dipropionate 2 puffs by metered-dose
inhaler. The nurse plans to give these medications in which
way to ensure effectiveness?
✓ Administering the pirbuterol
before the beclomethasone
5) A client with chronic obstructive pulmonary disease (COPD)
is being changed from an oral glucocorticoid to
triamcinolone by inhalation. The client asks why this change
is necessary. Which statement by the nurse to the client is
accurate?
✓ "Inhaled glucocorticoids are
preferred because of decreased
adverse effects."
6) A client taking theophylline has a serum theophylline level
of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this
laboratory value?
✓ In the middle of the
therapeutic range
7) A client is taking cetirizine. The nurse should inform the
client of which side effect of this medication?
,SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR
✓ Drowsiness
8) A client is scheduled to receive acetylcysteine 20% solution
diluted in 0.9% normal saline by nebulizer. Which outcome
would the nurse expect as a result of the administration of
this medication?
✓ Thinning of respiratory secretions
9) The health care provider prescribes cromolyn for the client
with asthma. The nurse identifies that the client correctly
understands the purpose of this medication when the client
states that the medication will produce which effect?
✓
10) The nurse is teaching a client about the effects of
diphenhydramine, an ingredient in the cough suppressant
prescribed for the client. The nurse should plan to tell the
client to take which measure while taking this medication?
✓ Avoid activities requiring mental
alertness.
11) The health care provider (HCP) has prescribed codeine
sulfate for a client with a nonproductive cough to suppress
the cough reflex. The nurse should teach the client to
monitor for which side effect of the medication?
✓ Constipation
12) A client has begun therapy with a xanthine
bronchodilator. The nurse determines that the client
understands dietary alterations if the client states to
limit which items while taking this medication? Select all
that apply.
✓ Coffee
✓ Chocolate
13) Which supplies should the nurse obtain for the
administration of ribavirin to a hospitalized child with
respiratory syncytial virus (RSV)?
✓ A mask and pair of goggles
14) The nurse is documenting information in a client's
chart when the electrocardiogram telemetry alarm sounds, and
the nurse notes that the client is in ventricular
,SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR
tachycardia (VT). The nurse rushes to the client's bedside
and should perform which assessment first?
✓ Check responsiveness
15) A client is brought into the emergency department in
ventricular fibrillation (VF). The nurse prepares to
defibrillate by placing defibrillation pads on which part of
the chest?
✓ To the right of the sternum and to
the left of the precordium
16) An adult client has been unsuccessfully defibrillated
for ventricular fibrillation, and cardiopulmonary
resuscitation (CPR) is resumed. The nurse confirms that CPR
is being administered effectively by noting which action
✓ The carotid pulse is palpable with
each compression.
17) The nurse is assigned the care of a client who
experienced a myocardial infarction and is being monitored
by cardiac telemetry. The nurse notes the sudden onset of
this cardiac rhythm on the monitor. The nurse should
immediately take which action? Refer to Figure.
View Figure
✓ Initiate cardiopulmonary
resuscitation (CPR).
18) To perform defibrillation, the defibrillator pads
should be placed in which areas of the client's chest?
✓ To the right of the sternum just
below the clavicle and to the left
side, just below and to the left of
the pectoral muscle
19) The nurse is caring for a client who is pulseless and
experiencing this dysrhythmia. Which interventions should
the nurse anticipate implementing in collaboration with the
health care provider (HCP)? Select all that apply. Refer to
Figure.
View Figure
✓ Prepare to administer amiodarone.
, SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR
✓ Prepare to administer epinephrine.
✓ Provide cardiopulmonary resuscitation
(CPR).
20) The nurse is performing cardiopulmonary resuscitation
(CPR) on a client who has had a cardiac arrest. An automatic
external defibrillator (AED) is available to treat the
client. Which activity will allow the nurse to assess the
client's cardiac rhythm?
✓ Apply adhesive patch electrodes to the
chest and move away from the client.
21) The nurse is teaching adult cardiopulmonary
resuscitation (CPR) guidelines to a group of laypeople. The
nurse observes the group correctly demonstrate 2-rescuer CPR
when which ratio of compressions to ventilations is
performed on the mannequin?
✓ 30:2
22) The nurse is teaching cardiopulmonary resuscitation
(CPR) to a group of community members. The nurse tells the
group that when chest compressions are performed on infants,
the sternum should be depressed how far?
✓ About 1½ inches (4 cm)
23) The nursing instructor teaches a group of students
about cardiopulmonary resuscitation. The instructor asks a
student to identify the most appropriate location at which
to assess the pulse of an infant younger than 1 year of age.
Which response would indicate that the student understands
the appropriate assessment procedure?
✓ Brachial artery
24) The nurse is conducting a basic life support (BLS)
recertification class and is discussing chest compressions
in a pregnant woman. The nurse should tell the class that
which action should be taken in an advanced pregnancy client
whose fundal height is at or above the umbilicus?
✓ Maintain manual left uterine
displacement during compressions.
1) The nurse would anticipate that the health care provider
(HCP) would add which medication to the regimen of the
client receiving isoniazid?
✓ Pyridoxine
2) A postpartum nurse is caring for a client with an epidural
catheter in place for opioid analgesic administration
following cesarean birth. The client develops respiratory
depression and requires naloxone administration. Which
finding should the nurse anticipate as a result of the
naloxone administration?
✓ Increase in pain level
3) The nurse should monitor the client receiving the first dose
of albuterol for which side or adverse effect of this
medication?
✓ Tachycardia
4) The client has a prescription to receive pirbuterol 2 puffs
and beclomethasone dipropionate 2 puffs by metered-dose
inhaler. The nurse plans to give these medications in which
way to ensure effectiveness?
✓ Administering the pirbuterol
before the beclomethasone
5) A client with chronic obstructive pulmonary disease (COPD)
is being changed from an oral glucocorticoid to
triamcinolone by inhalation. The client asks why this change
is necessary. Which statement by the nurse to the client is
accurate?
✓ "Inhaled glucocorticoids are
preferred because of decreased
adverse effects."
6) A client taking theophylline has a serum theophylline level
of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this
laboratory value?
✓ In the middle of the
therapeutic range
7) A client is taking cetirizine. The nurse should inform the
client of which side effect of this medication?
,SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR
✓ Drowsiness
8) A client is scheduled to receive acetylcysteine 20% solution
diluted in 0.9% normal saline by nebulizer. Which outcome
would the nurse expect as a result of the administration of
this medication?
✓ Thinning of respiratory secretions
9) The health care provider prescribes cromolyn for the client
with asthma. The nurse identifies that the client correctly
understands the purpose of this medication when the client
states that the medication will produce which effect?
✓
10) The nurse is teaching a client about the effects of
diphenhydramine, an ingredient in the cough suppressant
prescribed for the client. The nurse should plan to tell the
client to take which measure while taking this medication?
✓ Avoid activities requiring mental
alertness.
11) The health care provider (HCP) has prescribed codeine
sulfate for a client with a nonproductive cough to suppress
the cough reflex. The nurse should teach the client to
monitor for which side effect of the medication?
✓ Constipation
12) A client has begun therapy with a xanthine
bronchodilator. The nurse determines that the client
understands dietary alterations if the client states to
limit which items while taking this medication? Select all
that apply.
✓ Coffee
✓ Chocolate
13) Which supplies should the nurse obtain for the
administration of ribavirin to a hospitalized child with
respiratory syncytial virus (RSV)?
✓ A mask and pair of goggles
14) The nurse is documenting information in a client's
chart when the electrocardiogram telemetry alarm sounds, and
the nurse notes that the client is in ventricular
,SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR
tachycardia (VT). The nurse rushes to the client's bedside
and should perform which assessment first?
✓ Check responsiveness
15) A client is brought into the emergency department in
ventricular fibrillation (VF). The nurse prepares to
defibrillate by placing defibrillation pads on which part of
the chest?
✓ To the right of the sternum and to
the left of the precordium
16) An adult client has been unsuccessfully defibrillated
for ventricular fibrillation, and cardiopulmonary
resuscitation (CPR) is resumed. The nurse confirms that CPR
is being administered effectively by noting which action
✓ The carotid pulse is palpable with
each compression.
17) The nurse is assigned the care of a client who
experienced a myocardial infarction and is being monitored
by cardiac telemetry. The nurse notes the sudden onset of
this cardiac rhythm on the monitor. The nurse should
immediately take which action? Refer to Figure.
View Figure
✓ Initiate cardiopulmonary
resuscitation (CPR).
18) To perform defibrillation, the defibrillator pads
should be placed in which areas of the client's chest?
✓ To the right of the sternum just
below the clavicle and to the left
side, just below and to the left of
the pectoral muscle
19) The nurse is caring for a client who is pulseless and
experiencing this dysrhythmia. Which interventions should
the nurse anticipate implementing in collaboration with the
health care provider (HCP)? Select all that apply. Refer to
Figure.
View Figure
✓ Prepare to administer amiodarone.
, SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR
✓ Prepare to administer epinephrine.
✓ Provide cardiopulmonary resuscitation
(CPR).
20) The nurse is performing cardiopulmonary resuscitation
(CPR) on a client who has had a cardiac arrest. An automatic
external defibrillator (AED) is available to treat the
client. Which activity will allow the nurse to assess the
client's cardiac rhythm?
✓ Apply adhesive patch electrodes to the
chest and move away from the client.
21) The nurse is teaching adult cardiopulmonary
resuscitation (CPR) guidelines to a group of laypeople. The
nurse observes the group correctly demonstrate 2-rescuer CPR
when which ratio of compressions to ventilations is
performed on the mannequin?
✓ 30:2
22) The nurse is teaching cardiopulmonary resuscitation
(CPR) to a group of community members. The nurse tells the
group that when chest compressions are performed on infants,
the sternum should be depressed how far?
✓ About 1½ inches (4 cm)
23) The nursing instructor teaches a group of students
about cardiopulmonary resuscitation. The instructor asks a
student to identify the most appropriate location at which
to assess the pulse of an infant younger than 1 year of age.
Which response would indicate that the student understands
the appropriate assessment procedure?
✓ Brachial artery
24) The nurse is conducting a basic life support (BLS)
recertification class and is discussing chest compressions
in a pregnant woman. The nurse should tell the class that
which action should be taken in an advanced pregnancy client
whose fundal height is at or above the umbilicus?
✓ Maintain manual left uterine
displacement during compressions.
