SAUNDERS COMPREHENSIVE REVIEW FOR THE NCLEX-
RN EXAMINATION COMPLETE EXAM TEST QUESTIONS
AND VERIFIED ANSWERS
1. The nurse is assigned to care for four clients on a medical-surgical
unit. Which client should the nurse assess first?
A. A client who is scheduled for a wound irrigation in 30 minutes
B. A client with type 1 diabetes mellitus who has a blood glucose level
of 180 mg/dL (10 mmol/L)
C. A client who is 2 hours post-total hip replacement and reports pain of
6 on a 0-10 scale
D. A client with a tracheostomy who has thick, yellow secretions and
decreased oxygen saturation
Answer: D
Rationale: Airway patency is always the highest priority. The client with
a tracheostomy and signs of a potential airway obstruction (thick
secretions, decreased oxygen saturation) requires immediate
intervention to prevent respiratory compromise. The other clients have
needs that are important but do not pose an immediate threat to
airway, breathing, or circulation.
2. The nurse is triaging clients in the emergency department. Which
client should be seen first?
,A. A client with a temperature of 38.8°C (101.8°F) and reports of muscle
aches
B. A client with a simple fracture of the right arm and requests pain
medication
C. A client with sudden onset of difficulty speaking and weakness on the
right side
D. A client with a minor laceration to the left hand sustained while
gardening
Answer: C
Rationale: In emergency triage, clients with acute neurological deficits
(sudden onset of speech difficulty and unilateral weakness) are
classified as emergent and require immediate evaluation for potential
stroke. This is the highest priority. The other clients have urgent or
nonurgent conditions that can wait.
3. In a team nursing model, which scenario best describes the
approach to client care?
A. An RN leads two LPNs and three APs in providing care to a group of
15 clients
B. Each staff member is assigned specific tasks for a group of clients
C. A single RN provides total care to 4 clients with the assistance of an
AP
D. An RN collaborates with a social worker to coordinate discharge
planning for a client
Answer: A
,Rationale: Team nursing is characterized by an RN leader who directs
and coordinates the care provided by a group of healthcare team
members (LPNs, APs) to a group of clients. Option B describes
functional nursing, option C describes primary nursing, and option D
describes case management.
4. The nurse is preparing to administer medications to four clients.
Which client should the nurse assess first before giving medications?
A. A client with hypertension who is due for metoprolol at 0900
B. A client with heart failure who has an apical pulse of 52 beats/min
and is due for digoxin
C. A client with diabetes who is requesting insulin before breakfast
D. A client with a urinary tract infection who is due for ciprofloxacin
Answer: B
Rationale: Digoxin should be held if the apical pulse is below 60
beats/min. The nurse must assess this client first to determine if the
medication should be withheld and to notify the healthcare provider.
This client's need is the priority because of the potential for digoxin
toxicity.
5. The nurse is caring for a client who is receiving a blood transfusion.
Which finding requires immediate action?
A. The client reports a mild headache
B. The client's temperature is 37.5°C (99.5°F)
C. The client develops low back pain and chills
D. The client's blood pressure is 138/88 mmHg
, Answer: C
Rationale: Low back pain and chills are classic signs of an acute
hemolytic transfusion reaction, which is life-threatening and requires
immediate action to stop the transfusion. The other findings are not
specific indicators of an acute transfusion reaction and would not
require immediate intervention.
6. The nurse is performing a sterile dressing change. Which action
indicates a break in sterile technique?
A. Placing the sterile field on a clean, dry surface at waist level
B. Opening the sterile package away from the body
C. Pouring sterile solution into a sterile basin held at waist level
D. Reaching over the sterile field to pick up a dropped sterile item
Answer: D
Rationale: Reaching over the sterile field contaminates it, as does
picking up a dropped item, which is no longer sterile. All other actions
maintain sterile technique. The sterile field must remain untouched and
anything below waist level or outside the sterile field is considered
contaminated.
7. The nurse is educating a client with newly diagnosed hypertension.
Which statement indicates the client understands the teaching?
A. "I will take my medication only when my blood pressure is high."
B. "I should check my blood pressure every month at the pharmacy."
C. "I need to limit my sodium intake and take my medication daily."
D. "I can stop my medication once my blood pressure is normal."
RN EXAMINATION COMPLETE EXAM TEST QUESTIONS
AND VERIFIED ANSWERS
1. The nurse is assigned to care for four clients on a medical-surgical
unit. Which client should the nurse assess first?
A. A client who is scheduled for a wound irrigation in 30 minutes
B. A client with type 1 diabetes mellitus who has a blood glucose level
of 180 mg/dL (10 mmol/L)
C. A client who is 2 hours post-total hip replacement and reports pain of
6 on a 0-10 scale
D. A client with a tracheostomy who has thick, yellow secretions and
decreased oxygen saturation
Answer: D
Rationale: Airway patency is always the highest priority. The client with
a tracheostomy and signs of a potential airway obstruction (thick
secretions, decreased oxygen saturation) requires immediate
intervention to prevent respiratory compromise. The other clients have
needs that are important but do not pose an immediate threat to
airway, breathing, or circulation.
2. The nurse is triaging clients in the emergency department. Which
client should be seen first?
,A. A client with a temperature of 38.8°C (101.8°F) and reports of muscle
aches
B. A client with a simple fracture of the right arm and requests pain
medication
C. A client with sudden onset of difficulty speaking and weakness on the
right side
D. A client with a minor laceration to the left hand sustained while
gardening
Answer: C
Rationale: In emergency triage, clients with acute neurological deficits
(sudden onset of speech difficulty and unilateral weakness) are
classified as emergent and require immediate evaluation for potential
stroke. This is the highest priority. The other clients have urgent or
nonurgent conditions that can wait.
3. In a team nursing model, which scenario best describes the
approach to client care?
A. An RN leads two LPNs and three APs in providing care to a group of
15 clients
B. Each staff member is assigned specific tasks for a group of clients
C. A single RN provides total care to 4 clients with the assistance of an
AP
D. An RN collaborates with a social worker to coordinate discharge
planning for a client
Answer: A
,Rationale: Team nursing is characterized by an RN leader who directs
and coordinates the care provided by a group of healthcare team
members (LPNs, APs) to a group of clients. Option B describes
functional nursing, option C describes primary nursing, and option D
describes case management.
4. The nurse is preparing to administer medications to four clients.
Which client should the nurse assess first before giving medications?
A. A client with hypertension who is due for metoprolol at 0900
B. A client with heart failure who has an apical pulse of 52 beats/min
and is due for digoxin
C. A client with diabetes who is requesting insulin before breakfast
D. A client with a urinary tract infection who is due for ciprofloxacin
Answer: B
Rationale: Digoxin should be held if the apical pulse is below 60
beats/min. The nurse must assess this client first to determine if the
medication should be withheld and to notify the healthcare provider.
This client's need is the priority because of the potential for digoxin
toxicity.
5. The nurse is caring for a client who is receiving a blood transfusion.
Which finding requires immediate action?
A. The client reports a mild headache
B. The client's temperature is 37.5°C (99.5°F)
C. The client develops low back pain and chills
D. The client's blood pressure is 138/88 mmHg
, Answer: C
Rationale: Low back pain and chills are classic signs of an acute
hemolytic transfusion reaction, which is life-threatening and requires
immediate action to stop the transfusion. The other findings are not
specific indicators of an acute transfusion reaction and would not
require immediate intervention.
6. The nurse is performing a sterile dressing change. Which action
indicates a break in sterile technique?
A. Placing the sterile field on a clean, dry surface at waist level
B. Opening the sterile package away from the body
C. Pouring sterile solution into a sterile basin held at waist level
D. Reaching over the sterile field to pick up a dropped sterile item
Answer: D
Rationale: Reaching over the sterile field contaminates it, as does
picking up a dropped item, which is no longer sterile. All other actions
maintain sterile technique. The sterile field must remain untouched and
anything below waist level or outside the sterile field is considered
contaminated.
7. The nurse is educating a client with newly diagnosed hypertension.
Which statement indicates the client understands the teaching?
A. "I will take my medication only when my blood pressure is high."
B. "I should check my blood pressure every month at the pharmacy."
C. "I need to limit my sodium intake and take my medication daily."
D. "I can stop my medication once my blood pressure is normal."
