SAUNDERS NCLEX PRACTICE EXAM 2025/2026 QUESTIONS
WITH SOLUTIONS MARKED A+
✔✔The nurse is monitoring a client who has a closed chest tube drainage system. The
nurse notes fluctuation of the fluid level in the water-seal chamber during inspiration and
expiration. On the basis of this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - ✔✔2-The chest
tube is functioning as expected.
The presence of fluctuation of the fluid level in the water-seal chamber indicates a
patent drainage system. With normal breathing, the water level rises with inspiration and
falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not
working properly, or if the lung has re-expanded. Options 1, 3, and 4 are incorrect
interpretations of the finding. An air leak may cause excessive bubbling in the water
seal chamber. Excessive and vigorous bubbling in the suction control chamber may
indicate that the amount of suction needs to be decreased. The status of the dressing is
not specifically related to the presence of fluctuation of the fluid level in the water-seal
chamber
✔✔A nurse is providing morning care to a client who has a closed chest tube drainage
system to treat a pneumothorax. When the nurse turns the client to the side, the chest
tube is accidentally dislodged from the chest. The nurse immediately applies sterile
gauze over the chest tube insertion site. Which is the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - ✔✔1-Call the health care provider.
If the chest drainage system is dislodged from the insertion site, the nurse immediately
applies sterile gauze over the site and calls the health care provider. The nurse would
maintain the client in an upright position. A new chest tube system may be attached if
the tube requires insertion, but this would not be the next action. Pulse oximetry
readings would assist in determining the client's respiratory status, but the priority action
would be to call the health care provider in this emergency situation.
✔✔A nurse reviews the medication history of a client and notes that the client is taking
leflunomide (Arava). During assessment of the client, the nurse should ask which
question to determine the effectiveness of this medication?
1-"Do you have any joint pain?"
,2-"Are you having any diarrhea?"
3-"Are you experiencing heartburn?"
4-"Do you have frequent headaches?" - ✔✔1-"Do you have any joint pain?"
Leflunomide is an immunomodulatory agent and has an anti-inflammatory action. The
medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a
side effect of the medication. Options 2, 3, and 4 are unrelated to the action, use, or
effectiveness of the medication.
✔✔A nurse is checking lochia discharge in a woman in the immediate postpartum
period. The nurse notes that the lochia is bright red and contains some small clots.
Based on this data, the nurse should make which interpretation?
1-The client is hemorrhaging.
2-The client needs to increase oral fluids.
3-The client is experiencing normal lochia discharge.
4-The client's health care provider needs to be notified of the finding. - ✔✔3-The client
is experiencing normal lochia discharge.
Lochia, the uterine discharge present after birth, initially is bright red and may contain
small clots. During the first 2 hours after birth, the amount of uterine discharge should
be approximately that of a heavy menstrual period. After that time, the lochial flow
should steadily decrease, and the color of the discharge should change to a pinkish red
or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4
are incorrect.
✔✔A nulliparous woman asks the nurse when she will begin to feel fetal movements.
The nurse responds by telling the woman that the first recognition of fetal movement will
occur at approximately how many weeks of gestation?
1-5 weeks
2-9 weeks
3-13 weeks
4-18 weeks - ✔✔4-18 weeks
The first recognition of fetal movements, or feeling life, by the multiparous woman may
occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice
these sensations until the 18 weeks' gestation or later. The first recognition of fetal
movement is called quickening.
✔✔A nurse is performing a vaginal assessment of a pregnant woman who is in labor.
The nurse notes that the umbilical cord is protruding from the vagina. The nurse would
immediately take which action?
1-Administer oxygen to the woman.
2-Transport the woman to the delivery room.
, 3-Place an external fetal monitor on the woman.
4-Exert upward pressure against the presenting part using a gloved hand. - ✔✔4-Exert
upward pressure against the presenting part using a gloved hand.
If the umbilical cord is protruding from the vagina, no attempt should be made to replace
it because doing so could traumatize it and further reduce blood flow. The nurse would
place a gloved hand into the vagina to the cervix and exert upward pressure against the
presenting part to relieve compression of the cord. The nurse also would wrap the cord
loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8
to 10 L/min by face mask, would be administered to the mother to increase fetal
oxygenation, and the woman would be prepared for immediate delivery. However, the
immediate action is to relieve pressure on the cord. The woman should already have an
external fetal monitor in place.
✔✔A nurse is assessing a woman in the second trimester of pregnancy who was
admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which
finding would the nurse expect to note if abruptio placentae is present?
1-Soft uterus
2-Abdominal pain
3-Nontender uterus
4-Painless vaginal bleeding - ✔✔2-Abdominal pain
Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal
pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is
present. Pains is mild to severe and either localized or diffuse over one region of the
uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender
uterus in the second or third trimester of pregnancy are signs of placenta previa.
✔✔A nurse in the labor room is caring for a client who is in the first stage of labor. On
assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate
(FHR) on the monitor strip. Based on this finding, which is the appropriate nursing
action?
1-Contact the health care provider.
2-Place the mother in a Trendelenburg position.
3-Administer oxygen to the client by face mask.
4-Document the findings and continue to monitor fetal patterns - ✔✔4-Document the
findings and continue to monitor fetal patterns
Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by
a return to baseline, in response to compression of the fetal head. It is a normal and
benign finding. Because early decelerations are considered benign, interventions are
not necessary. Therefore, options 1, 2, and 3 are unnecessary.
WITH SOLUTIONS MARKED A+
✔✔The nurse is monitoring a client who has a closed chest tube drainage system. The
nurse notes fluctuation of the fluid level in the water-seal chamber during inspiration and
expiration. On the basis of this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - ✔✔2-The chest
tube is functioning as expected.
The presence of fluctuation of the fluid level in the water-seal chamber indicates a
patent drainage system. With normal breathing, the water level rises with inspiration and
falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not
working properly, or if the lung has re-expanded. Options 1, 3, and 4 are incorrect
interpretations of the finding. An air leak may cause excessive bubbling in the water
seal chamber. Excessive and vigorous bubbling in the suction control chamber may
indicate that the amount of suction needs to be decreased. The status of the dressing is
not specifically related to the presence of fluctuation of the fluid level in the water-seal
chamber
✔✔A nurse is providing morning care to a client who has a closed chest tube drainage
system to treat a pneumothorax. When the nurse turns the client to the side, the chest
tube is accidentally dislodged from the chest. The nurse immediately applies sterile
gauze over the chest tube insertion site. Which is the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - ✔✔1-Call the health care provider.
If the chest drainage system is dislodged from the insertion site, the nurse immediately
applies sterile gauze over the site and calls the health care provider. The nurse would
maintain the client in an upright position. A new chest tube system may be attached if
the tube requires insertion, but this would not be the next action. Pulse oximetry
readings would assist in determining the client's respiratory status, but the priority action
would be to call the health care provider in this emergency situation.
✔✔A nurse reviews the medication history of a client and notes that the client is taking
leflunomide (Arava). During assessment of the client, the nurse should ask which
question to determine the effectiveness of this medication?
1-"Do you have any joint pain?"
,2-"Are you having any diarrhea?"
3-"Are you experiencing heartburn?"
4-"Do you have frequent headaches?" - ✔✔1-"Do you have any joint pain?"
Leflunomide is an immunomodulatory agent and has an anti-inflammatory action. The
medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a
side effect of the medication. Options 2, 3, and 4 are unrelated to the action, use, or
effectiveness of the medication.
✔✔A nurse is checking lochia discharge in a woman in the immediate postpartum
period. The nurse notes that the lochia is bright red and contains some small clots.
Based on this data, the nurse should make which interpretation?
1-The client is hemorrhaging.
2-The client needs to increase oral fluids.
3-The client is experiencing normal lochia discharge.
4-The client's health care provider needs to be notified of the finding. - ✔✔3-The client
is experiencing normal lochia discharge.
Lochia, the uterine discharge present after birth, initially is bright red and may contain
small clots. During the first 2 hours after birth, the amount of uterine discharge should
be approximately that of a heavy menstrual period. After that time, the lochial flow
should steadily decrease, and the color of the discharge should change to a pinkish red
or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4
are incorrect.
✔✔A nulliparous woman asks the nurse when she will begin to feel fetal movements.
The nurse responds by telling the woman that the first recognition of fetal movement will
occur at approximately how many weeks of gestation?
1-5 weeks
2-9 weeks
3-13 weeks
4-18 weeks - ✔✔4-18 weeks
The first recognition of fetal movements, or feeling life, by the multiparous woman may
occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice
these sensations until the 18 weeks' gestation or later. The first recognition of fetal
movement is called quickening.
✔✔A nurse is performing a vaginal assessment of a pregnant woman who is in labor.
The nurse notes that the umbilical cord is protruding from the vagina. The nurse would
immediately take which action?
1-Administer oxygen to the woman.
2-Transport the woman to the delivery room.
, 3-Place an external fetal monitor on the woman.
4-Exert upward pressure against the presenting part using a gloved hand. - ✔✔4-Exert
upward pressure against the presenting part using a gloved hand.
If the umbilical cord is protruding from the vagina, no attempt should be made to replace
it because doing so could traumatize it and further reduce blood flow. The nurse would
place a gloved hand into the vagina to the cervix and exert upward pressure against the
presenting part to relieve compression of the cord. The nurse also would wrap the cord
loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8
to 10 L/min by face mask, would be administered to the mother to increase fetal
oxygenation, and the woman would be prepared for immediate delivery. However, the
immediate action is to relieve pressure on the cord. The woman should already have an
external fetal monitor in place.
✔✔A nurse is assessing a woman in the second trimester of pregnancy who was
admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which
finding would the nurse expect to note if abruptio placentae is present?
1-Soft uterus
2-Abdominal pain
3-Nontender uterus
4-Painless vaginal bleeding - ✔✔2-Abdominal pain
Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal
pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is
present. Pains is mild to severe and either localized or diffuse over one region of the
uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender
uterus in the second or third trimester of pregnancy are signs of placenta previa.
✔✔A nurse in the labor room is caring for a client who is in the first stage of labor. On
assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate
(FHR) on the monitor strip. Based on this finding, which is the appropriate nursing
action?
1-Contact the health care provider.
2-Place the mother in a Trendelenburg position.
3-Administer oxygen to the client by face mask.
4-Document the findings and continue to monitor fetal patterns - ✔✔4-Document the
findings and continue to monitor fetal patterns
Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by
a return to baseline, in response to compression of the fetal head. It is a normal and
benign finding. Because early decelerations are considered benign, interventions are
not necessary. Therefore, options 1, 2, and 3 are unnecessary.
