SAUNDERS NCLEX REVIEW |ACTUAL QUESTIONS
AND VERIFIED ANSWERS|BRAND NEW 2026-2027
UPDATE|GRADED A+
Question 1
The nurse is performing a measurement of fundal height in a client whose pregnancy has
reached 36 weeks of gestation. During the measurement the client begins to feel
lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the
nurse understands that which is the cause of the lightheadedness?
1.A full bladder
2.Emotional instability
3.Insufficient iron intake
4.Compression of the vena cava
CORRECT ANSWER
4.Compression of the vena cava.
Compression of the inferior vena cava and aorta by the uterus may cause supine
hypotension syndrome late in pregnancy. Having the woman turn onto her left side or
elevating the left buttock during fundal height measurement will prevent or correct the
problem. The remaining options are unrelated to this syndrome.
Question 2
The nursing student is writing a plan of care for a child who presents with an acute head
injury. The nursing instructor reviews the plan of care and praises the student for
identifying which assessment as a priority?
1.
Inspecting the scalp
2.
Pupillary assessment
3.
1
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,Airway and breathing
4.
Palpating the child's head
CORRECT ANSWER
3.Airway and breathing.
The first step in the emergency treatment of child with head injury includes the ABCs-
airway, breathing, and circulation-assessments. The other assessments are included
when evaluating a head injury, but the priority is ABC.
Question 3
A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the
client's record, the nurse should expect to note documentation of which characteristic sign
of SLE?
1.Fever
2.Fatigue
3.Skin lesions
4.Elevated red blood cell count
CORRECT ANSWER
3.Skin lesions.
Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue
disorder that can cause major body organs and systems to fail. The major skin
manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash.
Fever and fatigue may occur before and during exacerbation, but these signs and
symptoms are vague. Anemia is most likely to occur in SLE.
Question 4
The nurse is caring for a child with a diagnosis of neutropenia. Which nursing interventions
are most appropriate for a child placed in protective isolation for neutropenia? Select all
that apply.
2
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,1.
Place the child on a low-bacteria diet.
2.
Change dressings using sterile technique.
3.
Put flowers in a vase with water before placing in the room.
4.
Peel fruits and vegetables before allowing the child to eat them.
5.
Allow individuals who are ill to visit as long as they wear a mask.
CORRECT ANSWER
1.Place the child on a low-bacteria diet.
For the hospitalized neutropenic child, flowers or plants should not be kept in the room
because standing water and damp soil harbor Aspergillusand Pseudomonas species, to
which these children are very susceptible. Fruits and vegetables not peeled before being
eaten harbor molds and should be avoided until the white blood cell count rises. The
child is placed on a low-bacteria diet. Dressings are always changed using sterile
technique. Individuals who are ill are not allowed to visit the client.
Question 5
The nurse is reviewing the laboratory test results for a client who takes 325 mg of
acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes.
What blood level should the nurse review?
1.Hemoglobin (Hgb)
2.Prothrombin time (PT)
3.Red blood cell (RBC) level
4.Partial thromboplastin time (PTT)
CORRECT ANSWER
2.Prothrombin time (PT).
3
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, PT is used to evaluate the adequacy of the extrinsic system and common pathway in the
clotting mechanism. When clotting factors exist in deficient quantities, the PT is
prolonged. Many diseases and medications such as salicylates are associated with
decreased PTs. PT is also used to monitor the adequacy of warfarin therapy. The Hgb
level is related to oxygen and carbon dioxide transport. Hgb concentration serves as the
oxygen-carrying capacity of the blood and also acts as an important acid-base buffer
system. The RBC level is helpful in identifying the cause of anemia and the presence of
other diseases. The PTT is used to evaluate the intrinsic system and the common
pathway of clot formation and is most commonly used to monitor heparin therapy.
Question 6
The nurse is caring for a client with full-thickness circumferential burns of the entire trunk
of the body. Which finding suggests that an escharotomy may be necessary?
1.Pallor of all extremities
2.Pulse oximetry reading of 93%
3.Peripheral pulses are diminished
4.High pressure alarm keeps sounding on the ventilator
CORRECT ANSWER
4.High pressure alarm keeps sounding on the ventilator.
A client with a circumferential burn of the entire trunk likely will be on a ventilator
because of the potential for breathing to be affected by this injury. The high pressure
alarm will sound on the ventilator when there is any kind of obstruction. If the chest
cannot expand due to restriction by eschar and increasing edema, this results in
obstruction.
Question 7
The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse
should provide the client with which information about the procedure?
1.To examine the testicles while lying down
2.That the best time for the examination is after a shower
4
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AND VERIFIED ANSWERS|BRAND NEW 2026-2027
UPDATE|GRADED A+
Question 1
The nurse is performing a measurement of fundal height in a client whose pregnancy has
reached 36 weeks of gestation. During the measurement the client begins to feel
lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the
nurse understands that which is the cause of the lightheadedness?
1.A full bladder
2.Emotional instability
3.Insufficient iron intake
4.Compression of the vena cava
CORRECT ANSWER
4.Compression of the vena cava.
Compression of the inferior vena cava and aorta by the uterus may cause supine
hypotension syndrome late in pregnancy. Having the woman turn onto her left side or
elevating the left buttock during fundal height measurement will prevent or correct the
problem. The remaining options are unrelated to this syndrome.
Question 2
The nursing student is writing a plan of care for a child who presents with an acute head
injury. The nursing instructor reviews the plan of care and praises the student for
identifying which assessment as a priority?
1.
Inspecting the scalp
2.
Pupillary assessment
3.
1
@https://www.stuvia.com/user/thestudyvault
,Airway and breathing
4.
Palpating the child's head
CORRECT ANSWER
3.Airway and breathing.
The first step in the emergency treatment of child with head injury includes the ABCs-
airway, breathing, and circulation-assessments. The other assessments are included
when evaluating a head injury, but the priority is ABC.
Question 3
A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the
client's record, the nurse should expect to note documentation of which characteristic sign
of SLE?
1.Fever
2.Fatigue
3.Skin lesions
4.Elevated red blood cell count
CORRECT ANSWER
3.Skin lesions.
Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue
disorder that can cause major body organs and systems to fail. The major skin
manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash.
Fever and fatigue may occur before and during exacerbation, but these signs and
symptoms are vague. Anemia is most likely to occur in SLE.
Question 4
The nurse is caring for a child with a diagnosis of neutropenia. Which nursing interventions
are most appropriate for a child placed in protective isolation for neutropenia? Select all
that apply.
2
@https://www.stuvia.com/user/thestudyvault
,1.
Place the child on a low-bacteria diet.
2.
Change dressings using sterile technique.
3.
Put flowers in a vase with water before placing in the room.
4.
Peel fruits and vegetables before allowing the child to eat them.
5.
Allow individuals who are ill to visit as long as they wear a mask.
CORRECT ANSWER
1.Place the child on a low-bacteria diet.
For the hospitalized neutropenic child, flowers or plants should not be kept in the room
because standing water and damp soil harbor Aspergillusand Pseudomonas species, to
which these children are very susceptible. Fruits and vegetables not peeled before being
eaten harbor molds and should be avoided until the white blood cell count rises. The
child is placed on a low-bacteria diet. Dressings are always changed using sterile
technique. Individuals who are ill are not allowed to visit the client.
Question 5
The nurse is reviewing the laboratory test results for a client who takes 325 mg of
acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes.
What blood level should the nurse review?
1.Hemoglobin (Hgb)
2.Prothrombin time (PT)
3.Red blood cell (RBC) level
4.Partial thromboplastin time (PTT)
CORRECT ANSWER
2.Prothrombin time (PT).
3
@https://www.stuvia.com/user/thestudyvault
, PT is used to evaluate the adequacy of the extrinsic system and common pathway in the
clotting mechanism. When clotting factors exist in deficient quantities, the PT is
prolonged. Many diseases and medications such as salicylates are associated with
decreased PTs. PT is also used to monitor the adequacy of warfarin therapy. The Hgb
level is related to oxygen and carbon dioxide transport. Hgb concentration serves as the
oxygen-carrying capacity of the blood and also acts as an important acid-base buffer
system. The RBC level is helpful in identifying the cause of anemia and the presence of
other diseases. The PTT is used to evaluate the intrinsic system and the common
pathway of clot formation and is most commonly used to monitor heparin therapy.
Question 6
The nurse is caring for a client with full-thickness circumferential burns of the entire trunk
of the body. Which finding suggests that an escharotomy may be necessary?
1.Pallor of all extremities
2.Pulse oximetry reading of 93%
3.Peripheral pulses are diminished
4.High pressure alarm keeps sounding on the ventilator
CORRECT ANSWER
4.High pressure alarm keeps sounding on the ventilator.
A client with a circumferential burn of the entire trunk likely will be on a ventilator
because of the potential for breathing to be affected by this injury. The high pressure
alarm will sound on the ventilator when there is any kind of obstruction. If the chest
cannot expand due to restriction by eschar and increasing edema, this results in
obstruction.
Question 7
The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse
should provide the client with which information about the procedure?
1.To examine the testicles while lying down
2.That the best time for the examination is after a shower
4
@https://www.stuvia.com/user/thestudyvault
