SAUNDERS NCLEX QUESTIONS &
AMSWERS RATED 100% CORRECT
LATEST UPDATE
The nurse is monitoring the behavior of the client and understands that the client with anorexia
nervosa manages anxiety by which action? - correct answer ✔✔Clients with anorexia nervosa
have the desire to please others. Their need to be correct or perfect interferes with rational
decision-making processes. These clients are moralistic. Rules and rituals help the clients
manage their anxiety.
The nurse has given the client diagnosed with hepatitis instructions about post discharge
management during convalescence. The nurse determines a need for further teaching if the
client makes which statement?
1."I should avoid alcohol and aspirin."
2."I should eat a high-carbohydrate, low-fat diet."
3."I should resume a full activity level within 1 week."
4."I should take the prescribed amounts of vitamin K." - correct answer ✔✔The client with
hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is
important for the client to get adequate rest so that the liver may heal. The client should take in
a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as
aspirin and alcohol. If prescribed for prolonged clotting times the client should take vitamin K
The nurse is checking a client's record for probable signs of pregnancy. Which are the probable
signs of pregnancy that the nurse should note? Select all that apply. - correct answer ✔✔The
probable signs of pregnancy include uterine enlargement; Hegar's sign (the compressibility and
softening of the lower uterine segment that occurs at about week 6); Goodell's sign (the
softening of the cervix that occurs at the beginning of the second month of pregnancy);
Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva
that occurs at about week 4); ballottement (the rebounding of the fetus against the examiner's
,fingers on palpation); Braxton Hicks contractions; and a positive pregnancy test that measures
for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is
detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a
nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are
palpable by the examiner; and an outline of the fetus via radiography or ultrasound.
A client is receiving heparin sodium by continuous intravenous (IV) infusion. The licensed
practical nurse (LPN) is concerned that the client received a bolus of medication when the
tubing was removed from the IV pump during a gown change. The LPN immediately notifies the
registered nurse or health care provider and then checks to see whether which medication is
available in the medication supply area in case it is prescribed? - correct answer ✔✔If the
tubing is removed from an IV pump and the tubing is not clamped, the client will receive a bolus
of the solution and the medication contained in the solution. The client who receives a bolus
dose of heparin is at risk for bleeding. A partial thromboplastin time (PTT) will be drawn and
evaluated. If the results of the PTT are too high, a dose of protamine sulfate, the antidote for
heparin, may be prescribed. Aminocaproic acid is an antifibrinolytic (inhibits clot breakdown).
Enoxaparin is an anticoagulant. Vitamin K is the antidote for warfarin sodium.
The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a
nursing student to identify the functions of the vagina. The student correctly responds by
identifying which functions? Select all that apply. - correct answer ✔✔The pelvis is a bony
structure that supports and protects the lower abdominal and internal reproductive organs. The
vagina is the female organ of coitus, allows discharge of the menstrual flow, and assists in the
passage of the fetus from the uterus to outside the mother's body during childbirth. The
fallopian tubes are lined with folded epithelium containing cilia that beat rhythmically toward
the uterine cavity to propel the ovum through the tube. The functions of the ovaries include sex
hormone production and maturation of an ovum during each reproductive cycle.
A client scheduled for a pulmonary angiography is fearful about the procedure and asks the
nurse if the procedure involves significant pain and radiation exposure. The nurse gives a
response to the client that provides reassurance, based on which understanding? - correct
answer ✔✔Pulmonary angiography involves minimal exposure to radiation. The procedure is
painless, although the client may feel discomfort with insertion of the needle for the catheter
that is used for dye injection. No and moderate pain and no exposure to radiation are incorrect.
, The nurse prepares to administer digoxin to a 3-year-old with a diagnosis of heart failure and
notes that the apical heart rate is 120 beats per minute. Which nursing action is appropriate? -
correct answer ✔✔The normal apical heart rate for a 3-year-old is 80 to 125 beats per minute.
Because the apical heart rate is within normal range, options 1, 3, and 4 are inappropriate.
The nurse is caring for a new postoperative client and is monitoring the client for signs of shock.
The nurse monitors for which signs of this postoperative complication? - correct answer
✔✔Postoperative hypotension or shock can have numerous causes such as inadequate
ventilation, side effects of anesthetic agents or preoperative medications, and fluid or blood
loss. The symptoms of shock include hypotension; tachycardia; cold, moist, pale, or cyanotic
skin; and increased restlessness and apprehension.
A client receiving therapy with carbidopa/levodopa is upset and tells the nurse that his urine
has turned a darker color since he began to take the medication. The client wants to discontinue
its use. In formulating a response to the client's concerns, how does the nurse interpret this
development? - correct answer ✔✔With carbidopa/levodopa therapy, a darkening of the urine
or sweat may occur. The client should be reassured that this is a harmless effect of the
medication, and its use should be continued. Options 1, 2, and 4 are incorrect interpretations.
A client newly diagnosed with chronic kidney disease will be receiving peritoneal dialysis. During
the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse
is appropriate? - correct answer ✔✔Pain during the inflow of dialysate is common during the
first few exchanges because of peritoneal irritation; however, it disappears after a week or two.
The infusion amount should not be decreased, and the infusion should not be slowed or
stopped.
The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse should place
the hands in which position to begin chest compressions? - correct answer ✔✔Chest
compressions are done by placing the hands on the lower half of the sternum. The locations in
options 2, 3, and 4 would not provide effective chest compressions.
The nurse is caring for a client who had a total knee replacement and was put on a continuous
passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the
AMSWERS RATED 100% CORRECT
LATEST UPDATE
The nurse is monitoring the behavior of the client and understands that the client with anorexia
nervosa manages anxiety by which action? - correct answer ✔✔Clients with anorexia nervosa
have the desire to please others. Their need to be correct or perfect interferes with rational
decision-making processes. These clients are moralistic. Rules and rituals help the clients
manage their anxiety.
The nurse has given the client diagnosed with hepatitis instructions about post discharge
management during convalescence. The nurse determines a need for further teaching if the
client makes which statement?
1."I should avoid alcohol and aspirin."
2."I should eat a high-carbohydrate, low-fat diet."
3."I should resume a full activity level within 1 week."
4."I should take the prescribed amounts of vitamin K." - correct answer ✔✔The client with
hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is
important for the client to get adequate rest so that the liver may heal. The client should take in
a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as
aspirin and alcohol. If prescribed for prolonged clotting times the client should take vitamin K
The nurse is checking a client's record for probable signs of pregnancy. Which are the probable
signs of pregnancy that the nurse should note? Select all that apply. - correct answer ✔✔The
probable signs of pregnancy include uterine enlargement; Hegar's sign (the compressibility and
softening of the lower uterine segment that occurs at about week 6); Goodell's sign (the
softening of the cervix that occurs at the beginning of the second month of pregnancy);
Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva
that occurs at about week 4); ballottement (the rebounding of the fetus against the examiner's
,fingers on palpation); Braxton Hicks contractions; and a positive pregnancy test that measures
for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is
detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a
nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are
palpable by the examiner; and an outline of the fetus via radiography or ultrasound.
A client is receiving heparin sodium by continuous intravenous (IV) infusion. The licensed
practical nurse (LPN) is concerned that the client received a bolus of medication when the
tubing was removed from the IV pump during a gown change. The LPN immediately notifies the
registered nurse or health care provider and then checks to see whether which medication is
available in the medication supply area in case it is prescribed? - correct answer ✔✔If the
tubing is removed from an IV pump and the tubing is not clamped, the client will receive a bolus
of the solution and the medication contained in the solution. The client who receives a bolus
dose of heparin is at risk for bleeding. A partial thromboplastin time (PTT) will be drawn and
evaluated. If the results of the PTT are too high, a dose of protamine sulfate, the antidote for
heparin, may be prescribed. Aminocaproic acid is an antifibrinolytic (inhibits clot breakdown).
Enoxaparin is an anticoagulant. Vitamin K is the antidote for warfarin sodium.
The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a
nursing student to identify the functions of the vagina. The student correctly responds by
identifying which functions? Select all that apply. - correct answer ✔✔The pelvis is a bony
structure that supports and protects the lower abdominal and internal reproductive organs. The
vagina is the female organ of coitus, allows discharge of the menstrual flow, and assists in the
passage of the fetus from the uterus to outside the mother's body during childbirth. The
fallopian tubes are lined with folded epithelium containing cilia that beat rhythmically toward
the uterine cavity to propel the ovum through the tube. The functions of the ovaries include sex
hormone production and maturation of an ovum during each reproductive cycle.
A client scheduled for a pulmonary angiography is fearful about the procedure and asks the
nurse if the procedure involves significant pain and radiation exposure. The nurse gives a
response to the client that provides reassurance, based on which understanding? - correct
answer ✔✔Pulmonary angiography involves minimal exposure to radiation. The procedure is
painless, although the client may feel discomfort with insertion of the needle for the catheter
that is used for dye injection. No and moderate pain and no exposure to radiation are incorrect.
, The nurse prepares to administer digoxin to a 3-year-old with a diagnosis of heart failure and
notes that the apical heart rate is 120 beats per minute. Which nursing action is appropriate? -
correct answer ✔✔The normal apical heart rate for a 3-year-old is 80 to 125 beats per minute.
Because the apical heart rate is within normal range, options 1, 3, and 4 are inappropriate.
The nurse is caring for a new postoperative client and is monitoring the client for signs of shock.
The nurse monitors for which signs of this postoperative complication? - correct answer
✔✔Postoperative hypotension or shock can have numerous causes such as inadequate
ventilation, side effects of anesthetic agents or preoperative medications, and fluid or blood
loss. The symptoms of shock include hypotension; tachycardia; cold, moist, pale, or cyanotic
skin; and increased restlessness and apprehension.
A client receiving therapy with carbidopa/levodopa is upset and tells the nurse that his urine
has turned a darker color since he began to take the medication. The client wants to discontinue
its use. In formulating a response to the client's concerns, how does the nurse interpret this
development? - correct answer ✔✔With carbidopa/levodopa therapy, a darkening of the urine
or sweat may occur. The client should be reassured that this is a harmless effect of the
medication, and its use should be continued. Options 1, 2, and 4 are incorrect interpretations.
A client newly diagnosed with chronic kidney disease will be receiving peritoneal dialysis. During
the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse
is appropriate? - correct answer ✔✔Pain during the inflow of dialysate is common during the
first few exchanges because of peritoneal irritation; however, it disappears after a week or two.
The infusion amount should not be decreased, and the infusion should not be slowed or
stopped.
The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse should place
the hands in which position to begin chest compressions? - correct answer ✔✔Chest
compressions are done by placing the hands on the lower half of the sternum. The locations in
options 2, 3, and 4 would not provide effective chest compressions.
The nurse is caring for a client who had a total knee replacement and was put on a continuous
passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the
