Saunders NCLEX questions with correct answers
A+ Grade 2024\2025
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which
questions would the nurse ask the client? - correct answer The PQRSTU method is one method of
assessing pain. With this method, the nurse asks about the following: Precipitating factors (option 6);
Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of
the pain (continuous or intermittent); and How the pain affects you (option 4). Options 2 and 5 may be
questions that would be asked; however, these are not a part of the PQRSTU method.
The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure.
Which is the most important laboratory test result for the nurse to check before administering this
medication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level - correct answer Furosemide is a loop diuretic. The medication causes a decrease in
the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a
client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect
renal function. The cholesterol level is unrelated to the administration of this medication.
A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's
laboratory results and notes a hematocrit level of 30%. Which action should the nurse take?
1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record. - correct answer 1-Report the abnormally low
level.
,The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a female, depending
on age. A hematocrit level of 30% is a low level and would be reported to the health care provider
because it indicates blood loss; therefore options 2, 3, and 4 are incorrect.
A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The
nurse should tell the client to avoid which food item?
1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese - correct answer 2-Spinach
Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of
vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K
often are omitted from the diet. Vitamin K-rich foods include green leafy vegetables, fish, liver, coffee,
and tea.
A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device
complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that
the pulse rate has increased and the blood pressure has dropped. The nurse determines that the client
is most likely experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - correct answer 2-Air embolism
The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and
hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of
the client's chest. The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid
overload causes increased intravascular volume, which increases the blood pressure and the pulse rate
as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and
,shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance
depend on the type of imbalance the client is experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at
the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that
the IV rate has slowed. The nurse determines that which complication has occurred? - correct answer 1-
Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor,
coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When
the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or
stop. The corrective action is to remove the catheter and start a new IV line at another site. The
conditions identified in options 1, 2, and 4 are likely to be accompanied by warmth at the site, not
coolness.
A nurse provides instructions to a preoperative client about the use of an incentive spirometer. The
nurse determines that the client needs further instruction if the client indicates that he or she will take
which action?
1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale. - correct answer 4-After
maximal inspiration, hold the breath for 10 seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or
high Fowler's position. The mouthpiece should be covered completely and tightly while the client
inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client
should hold the breath for 2 or 3 seconds and then exhale slowly
, The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes
fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of
this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - correct answer 2-The chest tube is
functioning as expected.
The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage
system. With normal breathing, the water level rises with inspiration and falls with expiration.
Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has re-
expanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause
excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control
chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is
not specifically related to the presence of fluctuation of the fluid level in the water-seal chamber
A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a
pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged
from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is
the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - correct answer 1-Call the health care provider.
If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile
gauze over the site and calls the health care provider. The nurse would maintain the client in an upright
position. A new chest tube system may be attached if the tube requires insertion, but this would not be
the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but
the priority action would be to call the health care provider in this emergency situation.
A+ Grade 2024\2025
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which
questions would the nurse ask the client? - correct answer The PQRSTU method is one method of
assessing pain. With this method, the nurse asks about the following: Precipitating factors (option 6);
Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of
the pain (continuous or intermittent); and How the pain affects you (option 4). Options 2 and 5 may be
questions that would be asked; however, these are not a part of the PQRSTU method.
The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure.
Which is the most important laboratory test result for the nurse to check before administering this
medication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level - correct answer Furosemide is a loop diuretic. The medication causes a decrease in
the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a
client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect
renal function. The cholesterol level is unrelated to the administration of this medication.
A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's
laboratory results and notes a hematocrit level of 30%. Which action should the nurse take?
1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record. - correct answer 1-Report the abnormally low
level.
,The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a female, depending
on age. A hematocrit level of 30% is a low level and would be reported to the health care provider
because it indicates blood loss; therefore options 2, 3, and 4 are incorrect.
A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The
nurse should tell the client to avoid which food item?
1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese - correct answer 2-Spinach
Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of
vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K
often are omitted from the diet. Vitamin K-rich foods include green leafy vegetables, fish, liver, coffee,
and tea.
A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device
complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that
the pulse rate has increased and the blood pressure has dropped. The nurse determines that the client
is most likely experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - correct answer 2-Air embolism
The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and
hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of
the client's chest. The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid
overload causes increased intravascular volume, which increases the blood pressure and the pulse rate
as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and
,shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance
depend on the type of imbalance the client is experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at
the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that
the IV rate has slowed. The nurse determines that which complication has occurred? - correct answer 1-
Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor,
coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When
the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or
stop. The corrective action is to remove the catheter and start a new IV line at another site. The
conditions identified in options 1, 2, and 4 are likely to be accompanied by warmth at the site, not
coolness.
A nurse provides instructions to a preoperative client about the use of an incentive spirometer. The
nurse determines that the client needs further instruction if the client indicates that he or she will take
which action?
1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale. - correct answer 4-After
maximal inspiration, hold the breath for 10 seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or
high Fowler's position. The mouthpiece should be covered completely and tightly while the client
inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client
should hold the breath for 2 or 3 seconds and then exhale slowly
, The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes
fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of
this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - correct answer 2-The chest tube is
functioning as expected.
The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage
system. With normal breathing, the water level rises with inspiration and falls with expiration.
Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has re-
expanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause
excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control
chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is
not specifically related to the presence of fluctuation of the fluid level in the water-seal chamber
A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a
pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged
from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is
the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - correct answer 1-Call the health care provider.
If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile
gauze over the site and calls the health care provider. The nurse would maintain the client in an upright
position. A new chest tube system may be attached if the tube requires insertion, but this would not be
the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but
the priority action would be to call the health care provider in this emergency situation.
