Saunders Comprehensive Review for
the Nclex-RN Examination Questions
with Correct Answers
1. The nurse is assigned to care for four clients. In planning client rounds, which client
would the nurse assess first?
1. A postoperative client preparing for discharge with a new medication
2. A client requiring daily dressing changes of a recent surgical incision
3. A client scheduled for a chest x-ray after insertion of a nasogastric tube
4. A client with asthma who requested a breathing treatment during the previous shift -
ANSWERSAnswer: 4
Rationale: Airway is always the highest priority, and the nurse would attend to the client
with asthma who requested a breathing treatment during the previous shift. This could
indicate that the client was experiencing difficulty breathing. The clients described in
options 1, 2, and 3 have needs that would be identified as intermediate priorities.
2. The nurse employed in an emergency department is assigned to triage clients
coming to the emergency department for treatment on the evening shift. The nurse
would assign priority to which client?
1. A client complaining of muscle aches, a headache, and history of seizures
2. A client who twisted their ankle when rollerblading and is requesting medication for
pain
3. A client with a minor laceration on the index finger sustained while cutting an
eggplant
4. A client with chest pain who states that they just ate pizza that was made with a very
spicy sauce - ANSWERSAnswer: 4
Rationale: In an emergency department, triage involves brief client assessment to
classify clients according to their need for care and includes establishing priorities of
care. The type of illness or injury, the severity of the problem, and the resources
available govern the process. Clients with trauma, chest pain, severe respiratory
distress or cardiac arrest, limb amputation, or acute neurological deficits and those who
have sustained chemical splashes to the eyes are classified as emergent and are the
highest priority. Clients with conditions such as a simple fracture, asthma without
respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent
needs and are classified as a second priority. Clients with conditions such as a minor
laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority.
, 3. A nursing graduate is attending an agency orientation regarding the nursing model of
practice implemented in the health care facility. The nurse is told that the nursing model
is a team nursing approach. The nurse determines that which scenario is characteristic
of the team-based model of nursing practice?
1. Each staff member is assigned a specic task for a group of clients.
2. A staff member is assigned to determine the client's needs at home and begin
discharge planning.
3. A single registered nurse (RN) is responsible for providing care to a group of six
clients with the aid of an assistive personnel (AP).
4. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to
a group of 12 clients. - ANSWERSAnswer: 4
Rationale: In team nursing, nursing personnel are led by a registered nurse leader in
providing care to a group of clients. Option 1 identifies functional nursing. Option 2
identifies a component of case management. Option 3 identifies primary nursing
(relationship-based practice).
The nurse has received the assignment for the day shift. After making initial rounds and
checking all of the assigned clients, which client would the nurse plan to care for first?
1. A client who is ambulatory, demonstrating steady gait 2. A postoperative client who
has just received an opioid pain medication
3. A client scheduled for physical therapy for the first crutch-walking session
4. A client with a white blood cell count of 14,000 mm3 (14 × 109 /L) and a temperature
of 38.4° C - ANSWERSAnswer: 4
Rationale: The nurse would plan to care for the client who has an elevated white blood
cell count and a fever first, because this client's needs are the priority. The client who is
ambulatory with steady gait and the client scheduled for physical therapy for a crutch-
walking session do not have priority needs. Waiting for pain medication to take effect
before providing care to the postoperative client is best.
The nurse is giving a bed bath to an assigned client when an assistive personnel (AP)
enters the client's room and tells the nurse that another assigned client is in pain and
needs pain medication. Which is the most appropriate nursing action?
1. Finish the bed bath and then administer the pain medication to the other client.
2. Ask the AP to find out when the last pain medication was given to the client.
3. Ask the AP to tell the client in pain that medication will be administered as soon as
the bed bath is complete.
4. Cover the client, raise the side rails, tell the client that you will return shortly, and
administer the pain medication to the other client. - ANSWERSAnswer: 4
Rationale: The nurse is responsible for the care provided to assigned clients. The
appropriate action in this situation is to provide safety to the client who is receiving the
the Nclex-RN Examination Questions
with Correct Answers
1. The nurse is assigned to care for four clients. In planning client rounds, which client
would the nurse assess first?
1. A postoperative client preparing for discharge with a new medication
2. A client requiring daily dressing changes of a recent surgical incision
3. A client scheduled for a chest x-ray after insertion of a nasogastric tube
4. A client with asthma who requested a breathing treatment during the previous shift -
ANSWERSAnswer: 4
Rationale: Airway is always the highest priority, and the nurse would attend to the client
with asthma who requested a breathing treatment during the previous shift. This could
indicate that the client was experiencing difficulty breathing. The clients described in
options 1, 2, and 3 have needs that would be identified as intermediate priorities.
2. The nurse employed in an emergency department is assigned to triage clients
coming to the emergency department for treatment on the evening shift. The nurse
would assign priority to which client?
1. A client complaining of muscle aches, a headache, and history of seizures
2. A client who twisted their ankle when rollerblading and is requesting medication for
pain
3. A client with a minor laceration on the index finger sustained while cutting an
eggplant
4. A client with chest pain who states that they just ate pizza that was made with a very
spicy sauce - ANSWERSAnswer: 4
Rationale: In an emergency department, triage involves brief client assessment to
classify clients according to their need for care and includes establishing priorities of
care. The type of illness or injury, the severity of the problem, and the resources
available govern the process. Clients with trauma, chest pain, severe respiratory
distress or cardiac arrest, limb amputation, or acute neurological deficits and those who
have sustained chemical splashes to the eyes are classified as emergent and are the
highest priority. Clients with conditions such as a simple fracture, asthma without
respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent
needs and are classified as a second priority. Clients with conditions such as a minor
laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority.
, 3. A nursing graduate is attending an agency orientation regarding the nursing model of
practice implemented in the health care facility. The nurse is told that the nursing model
is a team nursing approach. The nurse determines that which scenario is characteristic
of the team-based model of nursing practice?
1. Each staff member is assigned a specic task for a group of clients.
2. A staff member is assigned to determine the client's needs at home and begin
discharge planning.
3. A single registered nurse (RN) is responsible for providing care to a group of six
clients with the aid of an assistive personnel (AP).
4. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to
a group of 12 clients. - ANSWERSAnswer: 4
Rationale: In team nursing, nursing personnel are led by a registered nurse leader in
providing care to a group of clients. Option 1 identifies functional nursing. Option 2
identifies a component of case management. Option 3 identifies primary nursing
(relationship-based practice).
The nurse has received the assignment for the day shift. After making initial rounds and
checking all of the assigned clients, which client would the nurse plan to care for first?
1. A client who is ambulatory, demonstrating steady gait 2. A postoperative client who
has just received an opioid pain medication
3. A client scheduled for physical therapy for the first crutch-walking session
4. A client with a white blood cell count of 14,000 mm3 (14 × 109 /L) and a temperature
of 38.4° C - ANSWERSAnswer: 4
Rationale: The nurse would plan to care for the client who has an elevated white blood
cell count and a fever first, because this client's needs are the priority. The client who is
ambulatory with steady gait and the client scheduled for physical therapy for a crutch-
walking session do not have priority needs. Waiting for pain medication to take effect
before providing care to the postoperative client is best.
The nurse is giving a bed bath to an assigned client when an assistive personnel (AP)
enters the client's room and tells the nurse that another assigned client is in pain and
needs pain medication. Which is the most appropriate nursing action?
1. Finish the bed bath and then administer the pain medication to the other client.
2. Ask the AP to find out when the last pain medication was given to the client.
3. Ask the AP to tell the client in pain that medication will be administered as soon as
the bed bath is complete.
4. Cover the client, raise the side rails, tell the client that you will return shortly, and
administer the pain medication to the other client. - ANSWERSAnswer: 4
Rationale: The nurse is responsible for the care provided to assigned clients. The
appropriate action in this situation is to provide safety to the client who is receiving the
