SAUNDERS NCLEX EXAM |ACTUAL QUESTIONS AND VERIFIED ANSWERS|BRAND NEW UPDATE|GRADED A+

SAUNDERS NCLEX EXAM |ACTUAL QUESTIONS
AND VERIFIED ANSWERS|BRAND NEW 2026-2027
UPDATE|GRADED A+


Question 1

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this
method, which questions would the nurse ask the client?

CORRECT ANSWER

The PQRSTU method is one method of assessing pain. With this method, the nurse asks
about the following: Precipitating factors (option 6); Quality of the pain (option 3); Region or
Radiation of the pain (option 1); Severity of the pain; Timing of the pain (continuous or
intermittent); and How the pain affects you (option 4). Options 2 and 5 may be questions
that would be asked; however, these are not a part of the PQRSTU method.




Question 2

The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart
failure. Which is the most important laboratory test result for the nurse to check before
administering this medication?



1-Blood urea nitrogen

2-Cholesterol level

3-Potassium level

4-Creatinine level

CORRECT ANSWER

Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes,
especially potassium, sodium, and chloride. Administering furosemide to a client with low
electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect renal
function. The cholesterol level is unrelated to the administration of this medication.




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,Question 3

A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the
client's laboratory results and notes a hematocrit level of 30%. Which action should the
nurse take?



1-Report the abnormally low level.

2-Report the abnormally high level.

3-Inform the client that the laboratory result is normal.

4-Place the normal report in the client's medical record.

CORRECT ANSWER

1-Report the abnormally low level.



The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a
female, depending on age. A hematocrit level of 30% is a low level and would be reported to
the health care provider because it indicates blood loss; therefore options 2, 3, and 4 are
incorrect.




Question 4

A nurse provides dietary instructions to a client who will be taking warfarin sodium
(Coumadin). The nurse should tell the client to avoid which food item?



1-Grapes

2-Spinach

3-Watermelon

4-Cottage cheese

CORRECT ANSWER

2-Spinach



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,Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the
action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant,
foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green
leafy vegetables, fish, liver, coffee, and tea.




Question 5

A client who has been receiving total parenteral nutrition (TPN) by way of a central venous
access device complains of chest pain and dyspnea. The nurse quickly assesses the client's
vital signs and notes that the pulse rate has increased and the blood pressure has
dropped. The nurse determines that the client is most likely experiencing which problem?



1-Sepsis

2-Air embolism

3-Fluid overload

4-Fluid imbalance

CORRECT ANSWER

2-Air embolism



The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety,
tachycardia, and hypotension. The nurse also may hear a loud churning sound over the
pericardium on auscultation of the client's chest. The signs and symptoms of sepsis include
fever, chills, and general malaise. Fluid overload causes increased intravascular volume,
which increases the blood pressure and the pulse rate as the heart tries to pump the extra
fluid volume. Fluid overload also causes neck vein distention and shifting of fluid into the
alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance depend on
the type of imbalance the client is experiencing.




Question 6



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, A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling
of tightness at the IV insertion site. On assessment, the nurse detects coolness and
swelling at the site and notes that the IV rate has slowed. The nurse determines that
which complication has occurred?

CORRECT ANSWER

1-Infection

2-Phlebitis

3-Infiltration

4-Thrombosis



An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous
tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the
subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing,
the flow of IV solution will slow down or stop. The corrective action is to remove the
catheter and start a new IV line at another site. The conditions identified in options 1, 2, and
4 are likely to be accompanied by warmth at the site, not coolness.




Question 7

A nurse provides instructions to a preoperative client about the use of an incentive
spirometer. The nurse determines that the client needs further instruction if the client
indicates that he or she will take which action?



1-Sit upright when using the device.

2-Inhale slowly, maintaining a constant flow.

3-Place the lips completely over the mouthpiece.

4-After maximal inspiration, hold the breath for 10 seconds and then exhale.

CORRECT ANSWER

4-After maximal inspiration, hold the breath for 10 seconds and then exhale.




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