Saunders Comprehensive Review for the
NCLEX-RN® Examination, 9th Edition by Linda
Anne Silvestri and Angela Silvestri – Ultimate
2025/2026 Study Guide for Guaranteed First-Time
Success and Avoiding Resits
1. A patient with chronic kidney disease (stage 4) is admitted with hyperkalemia (K+ 6.8 mEq/L)
and metabolic acidosis (pH 7.28, HCO3- 16 mEq/L). The electrocardiogram shows peaked T
waves. Which intervention requires immediate nursing action before administering sodium
polystyrene sulfonate?
A. Administer intravenous calcium gluconate
B. Initiate sodium bicarbonate infusion
C. Prepare for hemodialysis
D. Administer insulin and dextrose
Answer: A
Rationale: In life-threatening hyperkalemia with ECG changes, IV calcium gluconate is the priority to
stabilize cardiac membranes. Sodium polystyrene sulfonate works slowly (hours) and is not first-line for
acute emergencies. Insulin/dextrose shifts potassium intracellularly but calcium gluconate acts fastest to
protect the heart. Sodium bicarbonate is less effective in CKD-induced acidosis and does not address the
hyperkalemia immediately.
2. A nurse is evaluating a patient receiving intravenous heparin for a pulmonary embolism. The
activated partial thromboplastin time (aPTT) is 110 seconds (therapeutic range 60-80 seconds).
The patient has no signs of bleeding. What is the nurse's priority action?
A. Stop the heparin infusion immediately
B. Administer protamine sulfate
C. Decrease the heparin infusion rate
D. Notify the healthcare provider and obtain aPTT in 4 hours
Answer: C
Rationale: With a supratherapeutic aPTT but no bleeding, the heparin infusion should be decreased per
protocol to bring the aPTT back into range. Stopping heparin or administering protamine is reserved for
active bleeding or critical levels. Notifying the provider is appropriate but the nurse can independently
adjust the rate based on protocol. Waiting 4 hours without action risks prolonged anticoagulation.
Page 1
,3. A patient with type 2 diabetes mellitus is prescribed metformin and is scheduled for a computed
tomography (CT) scan with intravenous contrast. Which laboratory value requires the nurse to
hold the metformin and notify the healthcare provider?
A. Serum creatinine 1.2 mg/dL
B. eGFR 48 mL/min/1.73m²
C. Hemoglobin A1c 7.8%
D. Blood glucose 180 mg/dL
Answer: B
Rationale: Metformin should be held before and after contrast administration if eGFR is <60
mL/min/1.73m² due to risk of lactic acidosis. An eGFR of 48 indicates moderate renal impairment.
Serum creatinine 1.2 may be normal depending on muscle mass, but eGFR is a more accurate measure.
A1c and glucose levels are not contraindications for contrast.
4. A nurse is assessing a patient with suspected meningitis. The patient has a positive Kernig sign
and Brudzinski sign. Which cerebrospinal fluid (CSF) findings would the nurse anticipate in
bacterial meningitis?
A. Elevated glucose, elevated protein, increased neutrophils
B. Decreased glucose, elevated protein, increased neutrophils
C. Decreased glucose, decreased protein, increased lymphocytes
D. Elevated glucose, decreased protein, increased lymphocytes
Answer: B
Rationale: Bacterial meningitis typically shows decreased CSF glucose (due to bacterial consumption),
elevated protein (due to inflammation), and increased neutrophils (acute inflammatory response).
Option A has elevated glucose, which is not typical. Options C and D describe viral or fungal meningitis
patterns (lymphocytic predominance, normal/increased glucose).
5. A patient with severe preeclampsia is receiving intravenous magnesium sulfate. The nurse notes
the following: respiratory rate 10 breaths/min, deep tendon reflexes absent, urine output 20 mL
over the past 2 hours. Which action should the nurse take first?
A. Administer calcium gluconate
B. Stop the magnesium sulfate infusion
C. Increase intravenous fluids
D. Prepare for emergent cesarean delivery
Answer: B
Rationale: Magnesium sulfate toxicity presents with respiratory depression, areflexia, and oliguria. The
priority is to stop the infusion to prevent further toxicity. Calcium gluconate is the antidote but should be
administered after stopping the infusion. Increasing IV fluids may worsen pulmonary edema. Delivery
may be indicated but is not the immediate priority.
6. A nurse is caring for a patient with a chest tube connected to a dry suction water seal drainage
system. The suction control chamber is set at -20 cm H2O, but the water seal chamber shows
continuous bubbling. What is the most likely cause?
Page 2
,A. Suction pressure is too high
B. There is an air leak in the system
C. The chest tube is positioned against the mediastinum
D. The water seal chamber is overfilled
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the drainage system or
at the insertion site. Suction pressure settings do not cause continuous bubbling; excessive suction may
cause intermittent bubbling. Position against mediastinum or overfilling would not produce continuous
bubbling. The nurse should assess for leaks from connections or around the insertion site.
7. A patient with heart failure (HF) with reduced ejection fraction (HFrEF) is prescribed a
beta-blocker (metoprolol succinate) and an ACE inhibitor (lisinopril). Which assessment finding
indicates that the medications are achieving their therapeutic effect?
A. Heart rate 56 beats/min, blood pressure 90/60 mm Hg
B. Increased left ventricular ejection fraction from 35% to 45%
C. Serum potassium 5.8 mEq/L
D. Jugular venous distention and peripheral edema
Answer: B
Rationale: In HFrEF, beta-blockers and ACE inhibitors improve cardiac remodeling and increase
ejection fraction over time. A rise in LVEF from 35% to 45% indicates positive remodeling and
improved systolic function. Low heart rate and blood pressure are expected effects but not necessarily
therapeutic success if symptomatic. Hyperkalemia is a potential adverse effect of ACE inhibitors, not a
therapeutic goal. JVD and edema indicate worsening HF.
8. A nurse is administering packed red blood cells (PRBCs) to a patient. Fifteen minutes after the
infusion starts, the patient develops chills, fever (temperature 38.9°C), and lower back pain. What
is the priority nursing action?
A. Slow the infusion rate and administer antipyretics
B. Stop the transfusion and maintain IV access with normal saline
C. Increase the infusion rate to complete the transfusion quickly
D. Administer diphenhydramine and continue the transfusion
Answer: B
Rationale: These symptoms suggest a hemolytic transfusion reaction, which is life-threatening. The
priority is to stop the transfusion immediately to prevent further reaction and maintain IV access with
normal saline for potential hypotension. Slowing or continuing the transfusion could worsen the
reaction. Antipyretics and diphenhydramine are secondary interventions after stopping the transfusion.
9. A patient with a history of opioid use disorder is admitted for surgery. The anesthesia team
plans to use a multimodal analgesic approach. Which combination of medications is most
appropriate to manage acute postoperative pain while minimizing opioid use?
A. Acetaminophen, ibuprofen, and morphine as needed
B. Acetaminophen, ketorolac, and hydromorphone patient-controlled analgesia
C. Acetaminophen, gabapentin, and ketorolac with opioid rescue
Page 3
, D. Gabapentin, pregabalin, and fentanyl patch
Answer: C
Rationale: For patients with opioid use disorder, multimodal analgesia with non-opioid adjuvants is
preferred to reduce opioid requirements. Acetaminophen, gabapentin (for neuropathic pain), and
ketorolac (NSAID) provide synergistic analgesia. Opioid rescue is reserved for breakthrough pain.
Options A and B rely heavily on opioids as primary agents. Option D uses a fentanyl patch, which is
inappropriate for acute postoperative pain and carries high risk.
10. A nurse is evaluating a patient with acute respiratory distress syndrome (ARDS) who is on
volume-controlled mechanical ventilation. The plateau pressure is 35 cm H2O (normal <30), and
the tidal volume is set at 8 mL/kg ideal body weight. Which ventilator adjustment should the nurse
anticipate?
A. Increase positive end-expiratory pressure (PEEP) to improve oxygenation
B. Decrease tidal volume to 6 mL/kg ideal body weight
C. Increase respiratory rate to maintain minute ventilation
D. Switch to pressure-controlled ventilation
Answer: B
Rationale: High plateau pressure (>30 cm H2O) indicates risk of ventilator-induced lung injury. In
ARDS, lung-protective ventilation using low tidal volumes (6 mL/kg ideal body weight) is recommended
to reduce barotrauma. Increasing PEEP may improve oxygenation but does not address the high plateau
pressure. Increasing respiratory rate can maintain minute ventilation but tidal volume reduction is the
priority. Pressure-controlled ventilation may be considered but low tidal volume is the evidence-based
intervention.
11. A patient receiving mechanical ventilation has a sudden drop in oxygen saturation from 95% to
82%. The nurse notes decreased breath sounds on the right side and tracheal deviation to the left.
Which action should the nurse take first?
A. Perform chest physiotherapy
B. Administer a bolus of normal saline
C. Prepare for needle decompression
D. Increase the fraction of inspired oxygen
Answer: C
Rationale: The findings (decreased breath sounds on one side, tracheal deviation away from that side)
indicate tension pneumothorax, a life-threatening emergency. Needle decompression is the priority to
relieve pressure. Chest physiotherapy and fluid bolus are not indicated; increasing oxygen may be
secondary but does not address the underlying problem.
12. A patient with chronic kidney disease is prescribed sevelamer carbonate. The nurse
understands that this medication works by which mechanism?
A. Binding dietary phosphate in the gastrointestinal tract
B. Increasing renal excretion of phosphate
C. Inhibiting intestinal absorption of calcium
D. Promoting vitamin D synthesis in the kidneys
Page 4
NCLEX-RN® Examination, 9th Edition by Linda
Anne Silvestri and Angela Silvestri – Ultimate
2025/2026 Study Guide for Guaranteed First-Time
Success and Avoiding Resits
1. A patient with chronic kidney disease (stage 4) is admitted with hyperkalemia (K+ 6.8 mEq/L)
and metabolic acidosis (pH 7.28, HCO3- 16 mEq/L). The electrocardiogram shows peaked T
waves. Which intervention requires immediate nursing action before administering sodium
polystyrene sulfonate?
A. Administer intravenous calcium gluconate
B. Initiate sodium bicarbonate infusion
C. Prepare for hemodialysis
D. Administer insulin and dextrose
Answer: A
Rationale: In life-threatening hyperkalemia with ECG changes, IV calcium gluconate is the priority to
stabilize cardiac membranes. Sodium polystyrene sulfonate works slowly (hours) and is not first-line for
acute emergencies. Insulin/dextrose shifts potassium intracellularly but calcium gluconate acts fastest to
protect the heart. Sodium bicarbonate is less effective in CKD-induced acidosis and does not address the
hyperkalemia immediately.
2. A nurse is evaluating a patient receiving intravenous heparin for a pulmonary embolism. The
activated partial thromboplastin time (aPTT) is 110 seconds (therapeutic range 60-80 seconds).
The patient has no signs of bleeding. What is the nurse's priority action?
A. Stop the heparin infusion immediately
B. Administer protamine sulfate
C. Decrease the heparin infusion rate
D. Notify the healthcare provider and obtain aPTT in 4 hours
Answer: C
Rationale: With a supratherapeutic aPTT but no bleeding, the heparin infusion should be decreased per
protocol to bring the aPTT back into range. Stopping heparin or administering protamine is reserved for
active bleeding or critical levels. Notifying the provider is appropriate but the nurse can independently
adjust the rate based on protocol. Waiting 4 hours without action risks prolonged anticoagulation.
Page 1
,3. A patient with type 2 diabetes mellitus is prescribed metformin and is scheduled for a computed
tomography (CT) scan with intravenous contrast. Which laboratory value requires the nurse to
hold the metformin and notify the healthcare provider?
A. Serum creatinine 1.2 mg/dL
B. eGFR 48 mL/min/1.73m²
C. Hemoglobin A1c 7.8%
D. Blood glucose 180 mg/dL
Answer: B
Rationale: Metformin should be held before and after contrast administration if eGFR is <60
mL/min/1.73m² due to risk of lactic acidosis. An eGFR of 48 indicates moderate renal impairment.
Serum creatinine 1.2 may be normal depending on muscle mass, but eGFR is a more accurate measure.
A1c and glucose levels are not contraindications for contrast.
4. A nurse is assessing a patient with suspected meningitis. The patient has a positive Kernig sign
and Brudzinski sign. Which cerebrospinal fluid (CSF) findings would the nurse anticipate in
bacterial meningitis?
A. Elevated glucose, elevated protein, increased neutrophils
B. Decreased glucose, elevated protein, increased neutrophils
C. Decreased glucose, decreased protein, increased lymphocytes
D. Elevated glucose, decreased protein, increased lymphocytes
Answer: B
Rationale: Bacterial meningitis typically shows decreased CSF glucose (due to bacterial consumption),
elevated protein (due to inflammation), and increased neutrophils (acute inflammatory response).
Option A has elevated glucose, which is not typical. Options C and D describe viral or fungal meningitis
patterns (lymphocytic predominance, normal/increased glucose).
5. A patient with severe preeclampsia is receiving intravenous magnesium sulfate. The nurse notes
the following: respiratory rate 10 breaths/min, deep tendon reflexes absent, urine output 20 mL
over the past 2 hours. Which action should the nurse take first?
A. Administer calcium gluconate
B. Stop the magnesium sulfate infusion
C. Increase intravenous fluids
D. Prepare for emergent cesarean delivery
Answer: B
Rationale: Magnesium sulfate toxicity presents with respiratory depression, areflexia, and oliguria. The
priority is to stop the infusion to prevent further toxicity. Calcium gluconate is the antidote but should be
administered after stopping the infusion. Increasing IV fluids may worsen pulmonary edema. Delivery
may be indicated but is not the immediate priority.
6. A nurse is caring for a patient with a chest tube connected to a dry suction water seal drainage
system. The suction control chamber is set at -20 cm H2O, but the water seal chamber shows
continuous bubbling. What is the most likely cause?
Page 2
,A. Suction pressure is too high
B. There is an air leak in the system
C. The chest tube is positioned against the mediastinum
D. The water seal chamber is overfilled
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the drainage system or
at the insertion site. Suction pressure settings do not cause continuous bubbling; excessive suction may
cause intermittent bubbling. Position against mediastinum or overfilling would not produce continuous
bubbling. The nurse should assess for leaks from connections or around the insertion site.
7. A patient with heart failure (HF) with reduced ejection fraction (HFrEF) is prescribed a
beta-blocker (metoprolol succinate) and an ACE inhibitor (lisinopril). Which assessment finding
indicates that the medications are achieving their therapeutic effect?
A. Heart rate 56 beats/min, blood pressure 90/60 mm Hg
B. Increased left ventricular ejection fraction from 35% to 45%
C. Serum potassium 5.8 mEq/L
D. Jugular venous distention and peripheral edema
Answer: B
Rationale: In HFrEF, beta-blockers and ACE inhibitors improve cardiac remodeling and increase
ejection fraction over time. A rise in LVEF from 35% to 45% indicates positive remodeling and
improved systolic function. Low heart rate and blood pressure are expected effects but not necessarily
therapeutic success if symptomatic. Hyperkalemia is a potential adverse effect of ACE inhibitors, not a
therapeutic goal. JVD and edema indicate worsening HF.
8. A nurse is administering packed red blood cells (PRBCs) to a patient. Fifteen minutes after the
infusion starts, the patient develops chills, fever (temperature 38.9°C), and lower back pain. What
is the priority nursing action?
A. Slow the infusion rate and administer antipyretics
B. Stop the transfusion and maintain IV access with normal saline
C. Increase the infusion rate to complete the transfusion quickly
D. Administer diphenhydramine and continue the transfusion
Answer: B
Rationale: These symptoms suggest a hemolytic transfusion reaction, which is life-threatening. The
priority is to stop the transfusion immediately to prevent further reaction and maintain IV access with
normal saline for potential hypotension. Slowing or continuing the transfusion could worsen the
reaction. Antipyretics and diphenhydramine are secondary interventions after stopping the transfusion.
9. A patient with a history of opioid use disorder is admitted for surgery. The anesthesia team
plans to use a multimodal analgesic approach. Which combination of medications is most
appropriate to manage acute postoperative pain while minimizing opioid use?
A. Acetaminophen, ibuprofen, and morphine as needed
B. Acetaminophen, ketorolac, and hydromorphone patient-controlled analgesia
C. Acetaminophen, gabapentin, and ketorolac with opioid rescue
Page 3
, D. Gabapentin, pregabalin, and fentanyl patch
Answer: C
Rationale: For patients with opioid use disorder, multimodal analgesia with non-opioid adjuvants is
preferred to reduce opioid requirements. Acetaminophen, gabapentin (for neuropathic pain), and
ketorolac (NSAID) provide synergistic analgesia. Opioid rescue is reserved for breakthrough pain.
Options A and B rely heavily on opioids as primary agents. Option D uses a fentanyl patch, which is
inappropriate for acute postoperative pain and carries high risk.
10. A nurse is evaluating a patient with acute respiratory distress syndrome (ARDS) who is on
volume-controlled mechanical ventilation. The plateau pressure is 35 cm H2O (normal <30), and
the tidal volume is set at 8 mL/kg ideal body weight. Which ventilator adjustment should the nurse
anticipate?
A. Increase positive end-expiratory pressure (PEEP) to improve oxygenation
B. Decrease tidal volume to 6 mL/kg ideal body weight
C. Increase respiratory rate to maintain minute ventilation
D. Switch to pressure-controlled ventilation
Answer: B
Rationale: High plateau pressure (>30 cm H2O) indicates risk of ventilator-induced lung injury. In
ARDS, lung-protective ventilation using low tidal volumes (6 mL/kg ideal body weight) is recommended
to reduce barotrauma. Increasing PEEP may improve oxygenation but does not address the high plateau
pressure. Increasing respiratory rate can maintain minute ventilation but tidal volume reduction is the
priority. Pressure-controlled ventilation may be considered but low tidal volume is the evidence-based
intervention.
11. A patient receiving mechanical ventilation has a sudden drop in oxygen saturation from 95% to
82%. The nurse notes decreased breath sounds on the right side and tracheal deviation to the left.
Which action should the nurse take first?
A. Perform chest physiotherapy
B. Administer a bolus of normal saline
C. Prepare for needle decompression
D. Increase the fraction of inspired oxygen
Answer: C
Rationale: The findings (decreased breath sounds on one side, tracheal deviation away from that side)
indicate tension pneumothorax, a life-threatening emergency. Needle decompression is the priority to
relieve pressure. Chest physiotherapy and fluid bolus are not indicated; increasing oxygen may be
secondary but does not address the underlying problem.
12. A patient with chronic kidney disease is prescribed sevelamer carbonate. The nurse
understands that this medication works by which mechanism?
A. Binding dietary phosphate in the gastrointestinal tract
B. Increasing renal excretion of phosphate
C. Inhibiting intestinal absorption of calcium
D. Promoting vitamin D synthesis in the kidneys
Page 4
