SAUNDERS NCLEX Q&A BANK
(500+ MCQ, SATA, Case-based Questions)
1. A client with heart failure presents with edema and crackles. What is
the priority intervention?
A. Encourage fluids
B. Administer Furosemide
C. Increase sodium intake
D. Promote bed rest
Answer: B
Rationale: Reduces fluid overload
2. Which findings indicate fluid overload? (Select all that apply)
A. Weight gain
B. Edema
C. Crackles
D. Dry mucosa
E. Dyspnea
Answer: A, B, C, E
Rationale: Classic overload signs
3. A client with COPD has SpO₂ 84%. What is the priority action?
A. High-flow oxygen
B. No oxygen
C. Low-flow oxygen
D. Encourage exercise
Answer: C
Rationale: Prevent CO₂ retention
,4. Which symptoms are expected in hypoglycemia? (Select all that
apply)
A. Sweating
B. Tremors
C. Confusion
D. Polyuria
E. Tachycardia
Answer: A, B, C, E
Rationale: SNS response
5. A client is unconscious with blood glucose 35 mg/dL. What is the
first action?
A. Administer IV dextrose
B. Give insulin
C. Offer oral juice
D. Monitor
Answer: A
Rationale: Immediate treatment
6. A client on Heparin develops bleeding gums. What should the
nurse do?
A. Continue medication
B. Stop infusion
C. Increase dose
D. Delay action
Answer: B
Rationale: Prevent hemorrhage
7. Which precautions are required for heparin therapy? (Select all that
apply)
A. Use soft toothbrush
B. Avoid IM injections
, C. Monitor aPTT
D. Use razor blade
E. Assess bleeding
Answer: A, B, C, E
Rationale: Bleeding precautions
8. A client with MI reports chest pain unrelieved by Nitroglycerin.
What is the next action?
A. Encourage walking
B. Administer Morphine
C. Provide fluids
D. Ignore
Answer: B
Rationale: Pain control
9. Which ECG finding is associated with hyperkalemia?
A. Flat T waves
B. Peaked T waves
C. ST depression
D. Normal ECG
Answer: B
Rationale: Cardiac effect
10. A client with sepsis has BP 85/50 mmHg. What is the priority
intervention?
A. IV fluids
B. Sleep
C. Diet
D. Exercise
Answer: A
Rationale: Treat shock
, 11. Which findings indicate septic shock? (Select all that apply)
A. Hypotension
B. Tachycardia
C. Confusion
D. Bradycardia
E. Warm skin early
Answer: A, B, C, E
Rationale: Early sepsis
12. A client with stroke cannot swallow. What is the priority
nursing action?
A. Feed orally
B. Keep NPO
C. Offer water
D. Encourage chewing
Answer: B
Rationale: Prevent aspiration
13. Which complications are associated with stroke? (Select all
that apply)
A. Aspiration
B. DVT
C. Contractures
D. Hyperactivity
E. Pressure ulcers
Answer: A, B, C, E
Rationale: Immobility risks
14. A client with burns has low urine output. What is the cause?
A. Infection
B. Hypovolemic shock
C. Fever
(500+ MCQ, SATA, Case-based Questions)
1. A client with heart failure presents with edema and crackles. What is
the priority intervention?
A. Encourage fluids
B. Administer Furosemide
C. Increase sodium intake
D. Promote bed rest
Answer: B
Rationale: Reduces fluid overload
2. Which findings indicate fluid overload? (Select all that apply)
A. Weight gain
B. Edema
C. Crackles
D. Dry mucosa
E. Dyspnea
Answer: A, B, C, E
Rationale: Classic overload signs
3. A client with COPD has SpO₂ 84%. What is the priority action?
A. High-flow oxygen
B. No oxygen
C. Low-flow oxygen
D. Encourage exercise
Answer: C
Rationale: Prevent CO₂ retention
,4. Which symptoms are expected in hypoglycemia? (Select all that
apply)
A. Sweating
B. Tremors
C. Confusion
D. Polyuria
E. Tachycardia
Answer: A, B, C, E
Rationale: SNS response
5. A client is unconscious with blood glucose 35 mg/dL. What is the
first action?
A. Administer IV dextrose
B. Give insulin
C. Offer oral juice
D. Monitor
Answer: A
Rationale: Immediate treatment
6. A client on Heparin develops bleeding gums. What should the
nurse do?
A. Continue medication
B. Stop infusion
C. Increase dose
D. Delay action
Answer: B
Rationale: Prevent hemorrhage
7. Which precautions are required for heparin therapy? (Select all that
apply)
A. Use soft toothbrush
B. Avoid IM injections
, C. Monitor aPTT
D. Use razor blade
E. Assess bleeding
Answer: A, B, C, E
Rationale: Bleeding precautions
8. A client with MI reports chest pain unrelieved by Nitroglycerin.
What is the next action?
A. Encourage walking
B. Administer Morphine
C. Provide fluids
D. Ignore
Answer: B
Rationale: Pain control
9. Which ECG finding is associated with hyperkalemia?
A. Flat T waves
B. Peaked T waves
C. ST depression
D. Normal ECG
Answer: B
Rationale: Cardiac effect
10. A client with sepsis has BP 85/50 mmHg. What is the priority
intervention?
A. IV fluids
B. Sleep
C. Diet
D. Exercise
Answer: A
Rationale: Treat shock
, 11. Which findings indicate septic shock? (Select all that apply)
A. Hypotension
B. Tachycardia
C. Confusion
D. Bradycardia
E. Warm skin early
Answer: A, B, C, E
Rationale: Early sepsis
12. A client with stroke cannot swallow. What is the priority
nursing action?
A. Feed orally
B. Keep NPO
C. Offer water
D. Encourage chewing
Answer: B
Rationale: Prevent aspiration
13. Which complications are associated with stroke? (Select all
that apply)
A. Aspiration
B. DVT
C. Contractures
D. Hyperactivity
E. Pressure ulcers
Answer: A, B, C, E
Rationale: Immobility risks
14. A client with burns has low urine output. What is the cause?
A. Infection
B. Hypovolemic shock
C. Fever
