Saunders NCLEX-RN Comprehensive Review Mock
Examination (2026–2027)
Field of Study: Comprehensive Nursing / NCLEX-RN Review
Edition: 2026–2027
1. The nurse is caring for a client with heart failure who is receiving furosemide 40 mg IV push.
Which assessment finding indicates that the medication is having the desired therapeutic effect?
A) Blood pressure increases from 100/70 to 130/80 mmHg
B) Lung sounds change from coarse crackles to clear
C) Heart rate increases from 72 to 100 beats per minute
D) Urine specific gravity decreases to 1.002
Correct Answer: B
Rationale: Furosemide is a loop diuretic that reduces fluid overload; clearing of lung crackles
indicates resolution of pulmonary edema, which is the therapeutic goal. A rising blood pressure (A)
and increased heart rate (C) are not desired outcomes and may indicate over-diuresis or compensatory
mechanisms. Low specific gravity (D) indicates dilute urine but is not the primary indicator of
therapeutic effect for pulmonary edema. Strategy: Use the ABC framework – airway/breathing takes
priority.
2. The nurse is planning care for a client with a stage 3 pressure ulcer on the sacrum. Which
intervention is most important?
A) Massage the reddened area around the wound to stimulate circulation
B) Position the client in the supine position at all times
C) Reposition the client at least every 2 hours and use a pressure-relieving device
D) Clean the wound with full-strength hydrogen peroxide daily
Correct Answer: C
Rationale: Frequent repositioning and pressure-relieving devices reduce pressure on the wound and
,prevent further tissue breakdown, which is the priority. Massaging reddened areas (A) can further
damage fragile tissue. Supine positioning (B) places direct pressure on the sacrum. Hydrogen peroxide
(D) is cytotoxic and not recommended for wound cleansing. Strategy: Think about the principles of
pressure ulcer prevention – pressure relief is key.
3. The nurse is caring for a client with diabetes mellitus who is found unresponsive. Which action
should the nurse take first?
A) Administer 50% dextrose intravenously
B) Call the rapid response team
C) Check the blood glucose level
D) Administer glucagon subcutaneously
Correct Answer: C
Rationale: Before treating, the nurse must assess the blood glucose level to determine if the client is
hypoglycemic or hyperglycemic. Administering dextrose (A) or glucagon (D) without knowing the
glucose level could be harmful. Calling the rapid response team (B) may be necessary but is not the
first action; assessment is the initial step in the nursing process. Strategy: Remember the nursing
process – assess before intervening.
4. A client is receiving a continuous heparin infusion. The activated partial thromboplastin time
(aPTT) is 95 seconds (therapeutic range 46–70 seconds). What should the nurse do first?
A) Increase the heparin rate per protocol
B) Continue the infusion at the current rate
C) Stop the heparin infusion and notify the healthcare provider
D) Administer protamine sulfate immediately
Correct Answer: C
Rationale: An aPTT of 95 seconds indicates over-anticoagulation with a high risk of bleeding. The
infusion should be stopped and the provider notified for further orders. Protamine sulfate (D) is the
antidote but requires a prescription and is given for severe bleeding, not as the first action. Increasing
,the rate (A) or continuing (B) would increase bleeding risk. Strategy: For critically high lab values,
stop the infusion and notify the provider.
5. The nurse is caring for a client with a chest tube connected to water seal drainage. Continuous
bubbling is observed in the water seal chamber. After checking the system and finding no air leak
at the insertion site or connections, what should the nurse do next?
A) Clamp the chest tube
B) Notify the healthcare provider
C) Add more sterile water to the water seal chamber
D) Document the finding as normal
Correct Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak. If no external leak is
found, the leak may be within the client's pleural space or the system between the client and the
chamber, which requires provider notification. Clamping (A) requires an order. Adding water (C) does
not correct the leak. Intermittent bubbling with exhalation is normal (D). Strategy: Think about the
source of the air leak – if not external, it's internal and needs medical intervention.
6. A client with a history of heart failure has gained 3 pounds in 2 days and reports shortness of
breath. Which assessment should the nurse perform first?
A) Check for peripheral edema
B) Auscultate lung sounds
C) Measure abdominal girth
D) Assess urine output
Correct Answer: B
Rationale: Using the ABC priority framework, assessing respiratory status is the first action. Crackles
would indicate pulmonary edema. Edema (A), girth (C), and urine output (D) are important but not the
immediate priority. Strategy: Always prioritize airway and breathing.
, 7. The nurse is caring for a client with acute pancreatitis. Which laboratory result would the nurse
expect to be elevated?
A) Serum amylase and lipase
B) Blood urea nitrogen and creatinine
C) Aspartate aminotransferase and alanine aminotransferase
D) Troponin I
Correct Answer: A
Rationale: Amylase and lipase are pancreatic enzymes that are markedly elevated in acute pancreatitis.
BUN and creatinine (B) indicate renal function; AST and ALT (C) indicate liver function; troponin
(D) indicates myocardial damage. Strategy: Focus on the organ involved – pancreatitis affects the
pancreas, which produces amylase and lipase.
8. The nurse is assessing a client with a cast on the left forearm. The client reports unrelieved pain
despite medication, and the nurse notes that the fingers are pale and cool. What should the nurse
suspect?
A) Compartment syndrome
B) Infection
C) Deep vein thrombosis
D) Fat embolism
Correct Answer: A
Rationale: Unrelieved pain, pallor, and coolness are classic signs of compartment syndrome, a medical
emergency caused by increased pressure within the fascial compartments. Infection (B) would present
with fever and redness. DVT (C) causes swelling and pain but not necessarily pallor. Fat embolism (D)
causes respiratory distress and petechiae. Strategy: The "5 Ps" – pain, pallor, pulselessness,
paresthesia, paralysis – are signs of compartment syndrome.
9. A client is receiving a blood transfusion and develops chills, fever, and flank pain. What is the
priority nursing action?
Examination (2026–2027)
Field of Study: Comprehensive Nursing / NCLEX-RN Review
Edition: 2026–2027
1. The nurse is caring for a client with heart failure who is receiving furosemide 40 mg IV push.
Which assessment finding indicates that the medication is having the desired therapeutic effect?
A) Blood pressure increases from 100/70 to 130/80 mmHg
B) Lung sounds change from coarse crackles to clear
C) Heart rate increases from 72 to 100 beats per minute
D) Urine specific gravity decreases to 1.002
Correct Answer: B
Rationale: Furosemide is a loop diuretic that reduces fluid overload; clearing of lung crackles
indicates resolution of pulmonary edema, which is the therapeutic goal. A rising blood pressure (A)
and increased heart rate (C) are not desired outcomes and may indicate over-diuresis or compensatory
mechanisms. Low specific gravity (D) indicates dilute urine but is not the primary indicator of
therapeutic effect for pulmonary edema. Strategy: Use the ABC framework – airway/breathing takes
priority.
2. The nurse is planning care for a client with a stage 3 pressure ulcer on the sacrum. Which
intervention is most important?
A) Massage the reddened area around the wound to stimulate circulation
B) Position the client in the supine position at all times
C) Reposition the client at least every 2 hours and use a pressure-relieving device
D) Clean the wound with full-strength hydrogen peroxide daily
Correct Answer: C
Rationale: Frequent repositioning and pressure-relieving devices reduce pressure on the wound and
,prevent further tissue breakdown, which is the priority. Massaging reddened areas (A) can further
damage fragile tissue. Supine positioning (B) places direct pressure on the sacrum. Hydrogen peroxide
(D) is cytotoxic and not recommended for wound cleansing. Strategy: Think about the principles of
pressure ulcer prevention – pressure relief is key.
3. The nurse is caring for a client with diabetes mellitus who is found unresponsive. Which action
should the nurse take first?
A) Administer 50% dextrose intravenously
B) Call the rapid response team
C) Check the blood glucose level
D) Administer glucagon subcutaneously
Correct Answer: C
Rationale: Before treating, the nurse must assess the blood glucose level to determine if the client is
hypoglycemic or hyperglycemic. Administering dextrose (A) or glucagon (D) without knowing the
glucose level could be harmful. Calling the rapid response team (B) may be necessary but is not the
first action; assessment is the initial step in the nursing process. Strategy: Remember the nursing
process – assess before intervening.
4. A client is receiving a continuous heparin infusion. The activated partial thromboplastin time
(aPTT) is 95 seconds (therapeutic range 46–70 seconds). What should the nurse do first?
A) Increase the heparin rate per protocol
B) Continue the infusion at the current rate
C) Stop the heparin infusion and notify the healthcare provider
D) Administer protamine sulfate immediately
Correct Answer: C
Rationale: An aPTT of 95 seconds indicates over-anticoagulation with a high risk of bleeding. The
infusion should be stopped and the provider notified for further orders. Protamine sulfate (D) is the
antidote but requires a prescription and is given for severe bleeding, not as the first action. Increasing
,the rate (A) or continuing (B) would increase bleeding risk. Strategy: For critically high lab values,
stop the infusion and notify the provider.
5. The nurse is caring for a client with a chest tube connected to water seal drainage. Continuous
bubbling is observed in the water seal chamber. After checking the system and finding no air leak
at the insertion site or connections, what should the nurse do next?
A) Clamp the chest tube
B) Notify the healthcare provider
C) Add more sterile water to the water seal chamber
D) Document the finding as normal
Correct Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak. If no external leak is
found, the leak may be within the client's pleural space or the system between the client and the
chamber, which requires provider notification. Clamping (A) requires an order. Adding water (C) does
not correct the leak. Intermittent bubbling with exhalation is normal (D). Strategy: Think about the
source of the air leak – if not external, it's internal and needs medical intervention.
6. A client with a history of heart failure has gained 3 pounds in 2 days and reports shortness of
breath. Which assessment should the nurse perform first?
A) Check for peripheral edema
B) Auscultate lung sounds
C) Measure abdominal girth
D) Assess urine output
Correct Answer: B
Rationale: Using the ABC priority framework, assessing respiratory status is the first action. Crackles
would indicate pulmonary edema. Edema (A), girth (C), and urine output (D) are important but not the
immediate priority. Strategy: Always prioritize airway and breathing.
, 7. The nurse is caring for a client with acute pancreatitis. Which laboratory result would the nurse
expect to be elevated?
A) Serum amylase and lipase
B) Blood urea nitrogen and creatinine
C) Aspartate aminotransferase and alanine aminotransferase
D) Troponin I
Correct Answer: A
Rationale: Amylase and lipase are pancreatic enzymes that are markedly elevated in acute pancreatitis.
BUN and creatinine (B) indicate renal function; AST and ALT (C) indicate liver function; troponin
(D) indicates myocardial damage. Strategy: Focus on the organ involved – pancreatitis affects the
pancreas, which produces amylase and lipase.
8. The nurse is assessing a client with a cast on the left forearm. The client reports unrelieved pain
despite medication, and the nurse notes that the fingers are pale and cool. What should the nurse
suspect?
A) Compartment syndrome
B) Infection
C) Deep vein thrombosis
D) Fat embolism
Correct Answer: A
Rationale: Unrelieved pain, pallor, and coolness are classic signs of compartment syndrome, a medical
emergency caused by increased pressure within the fascial compartments. Infection (B) would present
with fever and redness. DVT (C) causes swelling and pain but not necessarily pallor. Fat embolism (D)
causes respiratory distress and petechiae. Strategy: The "5 Ps" – pain, pallor, pulselessness,
paresthesia, paralysis – are signs of compartment syndrome.
9. A client is receiving a blood transfusion and develops chills, fever, and flank pain. What is the
priority nursing action?
