Saunders Comprehensive Review for
the NCLEX-RN® Examination: 120
Practice Questions with Rationales
1. The nurse has received the client assignment for the day. Which
client should the nurse assess FIRST?
1. The client who has a nasogastric tube attached to
intermittent suction
2. The client who needs to receive subcutaneous insulin before
breakfast
3. The client who is 2 days postoperative and is complaining of
incisional pain
4. The client who has a blood glucose level of 50 mg/dL (2.8
mmol/L) and complains of blurred vision
Answer: 4
Rationale: This question addresses the subcategory Management
of Care in the Client Needs category Safe and Effective Care
Environment. The client in option 4 has a critically low blood
glucose level and is exhibiting symptoms of hypoglycemia
(blurred vision). This client should be assessed first so that
treatment can be implemented immediately. Hypoglycemia is an
urgent, potentially life-threatening condition that requires prompt
intervention. Although the other clients require nursing care, their
,situations do not represent the same level of immediate
physiological threat.
Test-Taking Strategy: Note the strategic word “first.” Establish
priorities by comparing the needs of each client and deciding
which need is urgent. Use Maslow‘s Hierarchy of Needs:
physiological needs (such as blood glucose alterations) take
priority over other concerns.
2. The nurse notes blanching, coolness, and edema at a peripheral
intravenous (IV) site. On the basis of these findings, the nurse
should implement which action FIRST?
1. Remove the IV
2. Apply a warm compress
3. Check for a blood return
4. Measure the area of infiltration
Answer: 1
Rationale: The findings described are classic signs of IV
infiltration (blanching, coolness, edema). Because infiltration can
be damaging to surrounding tissue, the appropriate first action is
to remove the IV to prevent further damage. Once the IV is
removed, further action would be taken depending on the
medication infusing and based on agency protocol.
Test-Taking Strategy: Focus on the strategic
word “first.” Identify that the client is experiencing an infiltration.
Consider the harmful effects of infiltration and determine the
,action to implement first—stopping the infusion prevents further
tissue damage.
3. 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?
1. Assess the client’s readiness to learn
2. Monitor blood pressure every 4 hours
3. Assess the IV site for signs of infection
4. Monitor respiratory status
Answer: 4
Rationale: Morphine sulfate is an opioid analgesic that can cause
respiratory depression as a serious adverse effect. The priority
nursing action when a client is receiving IV morphine is to monitor
respiratory status. Airway and breathing are the highest priorities.
While monitoring blood pressure, assessing the IV site, and
assessing readiness to learn are important, they are not the
priority over respiratory monitoring.
Test-Taking Strategy: Note the strategic word “priority.” Apply
the ABCs (Airway, Breathing, Circulation). Respiratory status
(breathing) takes precedence over other assessments when a
client is receiving an opioid medication that can depress the
respiratory drive.
, 4. The nurse is caring for a client who has just returned from
surgery with an indwelling urinary catheter. The nurse notes that
the urine output for the past 4 hours is 100 mL. What action
should the nurse take FIRST?
1. Notify the healthcare provider
2. Increase the IV fluid rate
3. Check the catheter tubing for kinks or obstruction
4. Administer a diuretic as prescribed
Answer: 3
Rationale: Inadequate urine output in a client with an indwelling
catheter may be caused by a kink or obstruction in the tubing.
Before notifying the healthcare provider or taking any other
action, the nurse should first check the catheter and tubing for
proper function. This is a simple assessment that may resolve the
issue without further intervention.
Test-Taking Strategy: Note the strategic word “first.” Always
perform a nursing assessment and check equipment function
before implementing invasive interventions or notifying the
healthcare provider.
5. The nurse is assigning care for a team consisting of a registered
nurse (RN), a licensed practical nurse (LPN), and two unlicensed
assistive personnel (UAP). Which client would be MOST
appropriate to assign to the LPN?
the NCLEX-RN® Examination: 120
Practice Questions with Rationales
1. The nurse has received the client assignment for the day. Which
client should the nurse assess FIRST?
1. The client who has a nasogastric tube attached to
intermittent suction
2. The client who needs to receive subcutaneous insulin before
breakfast
3. The client who is 2 days postoperative and is complaining of
incisional pain
4. The client who has a blood glucose level of 50 mg/dL (2.8
mmol/L) and complains of blurred vision
Answer: 4
Rationale: This question addresses the subcategory Management
of Care in the Client Needs category Safe and Effective Care
Environment. The client in option 4 has a critically low blood
glucose level and is exhibiting symptoms of hypoglycemia
(blurred vision). This client should be assessed first so that
treatment can be implemented immediately. Hypoglycemia is an
urgent, potentially life-threatening condition that requires prompt
intervention. Although the other clients require nursing care, their
,situations do not represent the same level of immediate
physiological threat.
Test-Taking Strategy: Note the strategic word “first.” Establish
priorities by comparing the needs of each client and deciding
which need is urgent. Use Maslow‘s Hierarchy of Needs:
physiological needs (such as blood glucose alterations) take
priority over other concerns.
2. The nurse notes blanching, coolness, and edema at a peripheral
intravenous (IV) site. On the basis of these findings, the nurse
should implement which action FIRST?
1. Remove the IV
2. Apply a warm compress
3. Check for a blood return
4. Measure the area of infiltration
Answer: 1
Rationale: The findings described are classic signs of IV
infiltration (blanching, coolness, edema). Because infiltration can
be damaging to surrounding tissue, the appropriate first action is
to remove the IV to prevent further damage. Once the IV is
removed, further action would be taken depending on the
medication infusing and based on agency protocol.
Test-Taking Strategy: Focus on the strategic
word “first.” Identify that the client is experiencing an infiltration.
Consider the harmful effects of infiltration and determine the
,action to implement first—stopping the infusion prevents further
tissue damage.
3. 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?
1. Assess the client’s readiness to learn
2. Monitor blood pressure every 4 hours
3. Assess the IV site for signs of infection
4. Monitor respiratory status
Answer: 4
Rationale: Morphine sulfate is an opioid analgesic that can cause
respiratory depression as a serious adverse effect. The priority
nursing action when a client is receiving IV morphine is to monitor
respiratory status. Airway and breathing are the highest priorities.
While monitoring blood pressure, assessing the IV site, and
assessing readiness to learn are important, they are not the
priority over respiratory monitoring.
Test-Taking Strategy: Note the strategic word “priority.” Apply
the ABCs (Airway, Breathing, Circulation). Respiratory status
(breathing) takes precedence over other assessments when a
client is receiving an opioid medication that can depress the
respiratory drive.
, 4. The nurse is caring for a client who has just returned from
surgery with an indwelling urinary catheter. The nurse notes that
the urine output for the past 4 hours is 100 mL. What action
should the nurse take FIRST?
1. Notify the healthcare provider
2. Increase the IV fluid rate
3. Check the catheter tubing for kinks or obstruction
4. Administer a diuretic as prescribed
Answer: 3
Rationale: Inadequate urine output in a client with an indwelling
catheter may be caused by a kink or obstruction in the tubing.
Before notifying the healthcare provider or taking any other
action, the nurse should first check the catheter and tubing for
proper function. This is a simple assessment that may resolve the
issue without further intervention.
Test-Taking Strategy: Note the strategic word “first.” Always
perform a nursing assessment and check equipment function
before implementing invasive interventions or notifying the
healthcare provider.
5. The nurse is assigning care for a team consisting of a registered
nurse (RN), a licensed practical nurse (LPN), and two unlicensed
assistive personnel (UAP). Which client would be MOST
appropriate to assign to the LPN?
