SAUNDERS NCLEX COMPREHENSIVE EXAM 2025/2026
QUESTIONS WITH SOLUTIONS MARKED A+
✔✔A client with diabetes mellitus demonstrates acute anxiety when admitted to the
hospital for the treatment of hyperglycemia. What is the appropriate intervention to
decrease the client's anxiety?
1.
Administer a sedative.
2.
Convey empathy, trust, and respect toward the client.
3.
Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear.
4.
Make sure that the client is familiar with the correct medical terms to promote
understanding of what is happening. - ✔✔Convey empathy, trust, and respect toward
the client.
Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The appropriate
intervention is to address the client's feelings related to the anxiety. Administering a
sedative is not the most appropriate intervention and does not address the source of the
client's anxiety. The nurse should not ignore the client's anxious feelings. Anxiety needs
to be managed before meaningful client education can occur.
✔✔The nurse provides instructions to a client newly diagnosed with type 1 diabetes
mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic
ketoacidosis when the client makes which statement?
1.
"I will stop taking my insulin if I'm too sick to eat."
2.
"I will decrease my insulin dose during times of illness."
3.
"I will adjust my insulin dose according to the level of glucose in my urine."
4.
"I will notify my health care provider (HCP) if my blood glucose level is higher than 250
mg/dL (14.2 mmol/L)." - ✔✔"I will notify my health care provider (HCP) if my blood
glucose level is higher than 250 mg/dL (14.2 mmol/L)."
During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic
ketoacidosis, due to hyperglycemia associated with the stress response and due to a
typically decreased caloric intake. As part of sick day management, the client with
diabetes should monitor blood glucose levels and should notify the HCP if the level is
higher than 250 mg/dL (14.2 mmol/L). Insulin should never be stopped. In fact, insulin
may need to be increased during times of illness. Doses should not be adjusted without
,the HCP's advice and are usually adjusted on the basis of blood glucose levels, not
urinary glucose readings.
✔✔A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The
initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV)
infusion of short-acting insulin is initiated, along with IV rehydration with normal saline.
The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse
would next prepare to administer which medication?
1.
An ampule of 50% dextrose
2.
NPH insulin subcutaneously
3.
IV fluids containing dextrose
4.
Phenytoin for the prevention of seizures - ✔✔IV fluids containing dextrose
Emergency management of DKA focuses on correcting fluid and electrolyte imbalances
and normalizing the serum glucose level. If the corrections occur too quickly, serious
consequences, including hypoglycemia and cerebral edema, can occur. During
management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to
17.1 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to
maintain a blood glucose level of about 250 mg/dL (14.2 mmol/L), or until the client
recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin
is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA.
✔✔The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of
complications. Which sign or symptom, if exhibited in the client, indicates that the client
is at risk for chronic complications of diabetes if the blood glucose is not adequately
managed?
1.
Polyuria
2.
Diaphoresis
3.
Pedal edema
4.
Decreased respiratory rate - ✔✔Polyuria
Chronic hyperglycemia, resulting from poor glycemic control, contributes to the
microvascular and macrovascular complications of diabetes mellitus. Classic symptoms
of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in
hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it
does not predispose a client to the chronic complications of diabetes mellitus.
,Therefore, option 2 can be eliminated because this finding is characteristic of
hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus.
✔✔The nurse is preparing a plan of care for a client with diabetes mellitus who has
hyperglycemia. The nurse places priority on which client problem?
1.
Lack of knowledge
2.
Inadequate fluid volume
3.
Compromised family coping
4.
Inadequate consumption of nutrients - ✔✔Inadequate fluid volume
An increased blood glucose level will cause the kidneys to excrete the glucose in the
urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic
diuresis leading to dehydration. This fluid loss must be replaced when it becomes
severe. Options 1, 3, and 4 are not related specifically to the information in the question.
✔✔The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus.
The client relates a history of vomiting and diarrhea and tells the nurse that no food has
been consumed for the last 24 hours. Which additional statement by the client indicates
a need for further teaching?
1.
"I need to stop my insulin."
2.
"I need to increase my fluid intake."
3.
"I need to monitor my blood glucose every 3 to 4 hours."
4.
"I need to call the health care provider (HCP) because of these symptoms." - ✔✔"I need
to stop my insulin."
When a client with diabetes mellitus is unable to eat normally because of illness, the
client still should take the prescribed insulin or oral medication. The client should
consume additional fluids and should notify the HCP. The client should monitor the
blood glucose level every 3 to 4 hours. The client should also monitor the urine for
ketones during illness.
✔✔The nurse is caring for a client after hypophysectomy and notes clear nasal
drainage from the client's nostril. The nurse should take which initial action?
, 1.
Lower the head of the bed.
2.
Test the drainage for glucose.
3.
Obtain a culture of the drainage.
4.
Continue to observe the drainage. - ✔✔Test the drainage for glucose.
After hypophysectomy, the client should be monitored for rhinorrhea, which could
indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and
tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and
if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the
bed should remain elevated to prevent increased intracranial pressure. Clear nasal
drainage would not indicate the need for a culture. Continuing to observe the drainage
without taking action could result in a serious complication.
✔✔The nurse is admitting a client who is diagnosed with syndrome of inappropriate
antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118
mmol/L). Which health care provider prescriptions should the nurse anticipate
receiving? Select all that apply.
1.
Initiate an infusion of 3% NaCl.
2.
Administer intravenous furosemide.
3.
Restrict fluids to 800 mL over 24 hours.
4.
Elevate the head of the bed to high Fowler's.
5.
Administer a vasopressin antagonist as prescribed. - ✔✔1.
Initiate an infusion of 3% NaCl.
3.
Restrict fluids to 800 mL over 24 hours.
5.
Administer a vasopressin antagonist as prescribed
Clients with SIADH experience excess secretion of antidiuretic hormone (ADH), which
leads to excess intravascular volume, a declining serum osmolarity, and dilutional
hyponatremia. Management is directed at correcting the hyponatremia and preventing
cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less
than 120 mEq/L (120 mmol/L). An intravenous (IV) infusion of 3% saline is hypertonic.
Hypertonic saline must be infused slowly as prescribed and an infusion pump must be
used. Fluid restriction is a useful strategy aimed at correcting dilutional hyponatremia.
Vasopressin is an ADH; vasopressin antagonists are used to treat SIADH. Furosemide
QUESTIONS WITH SOLUTIONS MARKED A+
✔✔A client with diabetes mellitus demonstrates acute anxiety when admitted to the
hospital for the treatment of hyperglycemia. What is the appropriate intervention to
decrease the client's anxiety?
1.
Administer a sedative.
2.
Convey empathy, trust, and respect toward the client.
3.
Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear.
4.
Make sure that the client is familiar with the correct medical terms to promote
understanding of what is happening. - ✔✔Convey empathy, trust, and respect toward
the client.
Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The appropriate
intervention is to address the client's feelings related to the anxiety. Administering a
sedative is not the most appropriate intervention and does not address the source of the
client's anxiety. The nurse should not ignore the client's anxious feelings. Anxiety needs
to be managed before meaningful client education can occur.
✔✔The nurse provides instructions to a client newly diagnosed with type 1 diabetes
mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic
ketoacidosis when the client makes which statement?
1.
"I will stop taking my insulin if I'm too sick to eat."
2.
"I will decrease my insulin dose during times of illness."
3.
"I will adjust my insulin dose according to the level of glucose in my urine."
4.
"I will notify my health care provider (HCP) if my blood glucose level is higher than 250
mg/dL (14.2 mmol/L)." - ✔✔"I will notify my health care provider (HCP) if my blood
glucose level is higher than 250 mg/dL (14.2 mmol/L)."
During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic
ketoacidosis, due to hyperglycemia associated with the stress response and due to a
typically decreased caloric intake. As part of sick day management, the client with
diabetes should monitor blood glucose levels and should notify the HCP if the level is
higher than 250 mg/dL (14.2 mmol/L). Insulin should never be stopped. In fact, insulin
may need to be increased during times of illness. Doses should not be adjusted without
,the HCP's advice and are usually adjusted on the basis of blood glucose levels, not
urinary glucose readings.
✔✔A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The
initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV)
infusion of short-acting insulin is initiated, along with IV rehydration with normal saline.
The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse
would next prepare to administer which medication?
1.
An ampule of 50% dextrose
2.
NPH insulin subcutaneously
3.
IV fluids containing dextrose
4.
Phenytoin for the prevention of seizures - ✔✔IV fluids containing dextrose
Emergency management of DKA focuses on correcting fluid and electrolyte imbalances
and normalizing the serum glucose level. If the corrections occur too quickly, serious
consequences, including hypoglycemia and cerebral edema, can occur. During
management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to
17.1 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to
maintain a blood glucose level of about 250 mg/dL (14.2 mmol/L), or until the client
recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin
is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA.
✔✔The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of
complications. Which sign or symptom, if exhibited in the client, indicates that the client
is at risk for chronic complications of diabetes if the blood glucose is not adequately
managed?
1.
Polyuria
2.
Diaphoresis
3.
Pedal edema
4.
Decreased respiratory rate - ✔✔Polyuria
Chronic hyperglycemia, resulting from poor glycemic control, contributes to the
microvascular and macrovascular complications of diabetes mellitus. Classic symptoms
of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in
hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it
does not predispose a client to the chronic complications of diabetes mellitus.
,Therefore, option 2 can be eliminated because this finding is characteristic of
hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus.
✔✔The nurse is preparing a plan of care for a client with diabetes mellitus who has
hyperglycemia. The nurse places priority on which client problem?
1.
Lack of knowledge
2.
Inadequate fluid volume
3.
Compromised family coping
4.
Inadequate consumption of nutrients - ✔✔Inadequate fluid volume
An increased blood glucose level will cause the kidneys to excrete the glucose in the
urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic
diuresis leading to dehydration. This fluid loss must be replaced when it becomes
severe. Options 1, 3, and 4 are not related specifically to the information in the question.
✔✔The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus.
The client relates a history of vomiting and diarrhea and tells the nurse that no food has
been consumed for the last 24 hours. Which additional statement by the client indicates
a need for further teaching?
1.
"I need to stop my insulin."
2.
"I need to increase my fluid intake."
3.
"I need to monitor my blood glucose every 3 to 4 hours."
4.
"I need to call the health care provider (HCP) because of these symptoms." - ✔✔"I need
to stop my insulin."
When a client with diabetes mellitus is unable to eat normally because of illness, the
client still should take the prescribed insulin or oral medication. The client should
consume additional fluids and should notify the HCP. The client should monitor the
blood glucose level every 3 to 4 hours. The client should also monitor the urine for
ketones during illness.
✔✔The nurse is caring for a client after hypophysectomy and notes clear nasal
drainage from the client's nostril. The nurse should take which initial action?
, 1.
Lower the head of the bed.
2.
Test the drainage for glucose.
3.
Obtain a culture of the drainage.
4.
Continue to observe the drainage. - ✔✔Test the drainage for glucose.
After hypophysectomy, the client should be monitored for rhinorrhea, which could
indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and
tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and
if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the
bed should remain elevated to prevent increased intracranial pressure. Clear nasal
drainage would not indicate the need for a culture. Continuing to observe the drainage
without taking action could result in a serious complication.
✔✔The nurse is admitting a client who is diagnosed with syndrome of inappropriate
antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118
mmol/L). Which health care provider prescriptions should the nurse anticipate
receiving? Select all that apply.
1.
Initiate an infusion of 3% NaCl.
2.
Administer intravenous furosemide.
3.
Restrict fluids to 800 mL over 24 hours.
4.
Elevate the head of the bed to high Fowler's.
5.
Administer a vasopressin antagonist as prescribed. - ✔✔1.
Initiate an infusion of 3% NaCl.
3.
Restrict fluids to 800 mL over 24 hours.
5.
Administer a vasopressin antagonist as prescribed
Clients with SIADH experience excess secretion of antidiuretic hormone (ADH), which
leads to excess intravascular volume, a declining serum osmolarity, and dilutional
hyponatremia. Management is directed at correcting the hyponatremia and preventing
cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less
than 120 mEq/L (120 mmol/L). An intravenous (IV) infusion of 3% saline is hypertonic.
Hypertonic saline must be infused slowly as prescribed and an infusion pump must be
used. Fluid restriction is a useful strategy aimed at correcting dilutional hyponatremia.
Vasopressin is an ADH; vasopressin antagonists are used to treat SIADH. Furosemide
