Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
INTEGRATED REVIEW — COMPREHENSIVE NCLEX
PRACTICE PACK [FUNDAMENTALS,
PHARMACOLOGY, MEDICAL-SURGICAL,
MATERNITY, PEDIATRIC, EMERGENCY, AND
SPECIALTY SYSTEMS] TEST BANK
A 72-year-old post-op client with decreased LOC has
respirations 8/min, O₂ saturation 86% on room air, and snoring
respirations. What is the nurse’s priority action?
A. Call rapid response
B. Open the airway and stimulate resps; apply oxygen via bag-
valve mask if no improvement
C. Raise head of bed and reposition for comfort
D. Obtain arterial blood gases (ABG)
Answer: B.
Rationale (correct): Immediate airway support and ventilation
,are first priority for respiratory depression; bag-valve mask if
patient fails to maintain airway/oxygenation. (Safe & Effective
Care Environment; Application)
A — Incorrect: Rapid response may be indicated, but immediate
airway support precedes calling for help.
C — Incorrect: Repositioning may help partial obstruction but is
insufficient for RR 8 and sat 86%.
D — Incorrect: ABG is diagnostic and not first; treat
airway/oxygenation first.
2 (Fundamentals) — SATA
Select measures to reduce risk of catheter-associated urinary
tract infection (CAUTI):
A. Keep catheter drainage bag below bladder level
B. Routinely irrigate catheter with sterile saline every 24 hours
C. Perform hand hygiene before and after manipulation
D. Secure catheter to prevent urethral traction
E. Replace catheter every 48 hours
Answers: A, C, D.
Rationales:
A — Correct: Prevents backflow.
B — Incorrect: Routine irrigation increases infection risk; only
do if obstruction or ordered.
C — Correct: Hand hygiene prevents contamination.
D — Correct: Reduces trauma and entry of organisms.
E — Incorrect: Routine scheduled replacement is not
,recommended and can increase trauma; replace only when
indicated.
(NCLEX category: Safe & Effective Care Environment;
Application)
3 (Fundamentals) — SBA
A client with dementia wanders at night. Best evidence-based
intervention to reduce fall risk?
A. Use soft wrist restraints during night
B. Increase room lighting and use motion sensor night lights
C. Keep bed in lowest position and place mattress on floor only
when fall occurs
D. Administer a PRN sedative at bedtime
Answer: B.
Rationale (correct): Environmental modifications (lighting,
sensors) reduce wandering risks and preserve autonomy.
(Safety / Psychosocial Integrity; Analysis)
A — Incorrect: Restraints are last resort and can cause harm.
C — Incorrect: Low bed is useful but reactive; lighting addresses
wandering.
D — Incorrect: Sedatives risk over-sedation and adverse events;
nonpharmacologic interventions preferred.
4 (Fundamentals) — SBA
, Which action best demonstrates adherence to professional
boundaries?
A. Accepting small gifts from family members
B. Sharing your personal phone number with a client for after-
hours questions
C. Arranging a private social meeting with a former patient
D. Discussing the client’s medical condition with the client’s
roommate
Answer: A.
Rationale (correct): Small tokens of appreciation are often
acceptable; must follow facility policy. (Safe & Effective Care;
Evaluation)
B — Incorrect: Sharing personal contact blurs boundaries and
raises safety/privacy issues.
C — Incorrect: Socializing can breach professional boundaries.
D — Incorrect: Confidentiality violation unless roommate is
designated decision-maker.
5 (Fundamentals) — Matrix (matching)
Match the infection control term (Column A) with the correct
action (Column B).
Column A: 1. Standard precautions, 2. Contact precautions, 3.
Droplet precautions, 4. Airborne precautions
Column B: A. N95 respirator, negative-pressure room; B. Mask
PN® Examination
9th Edition
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
INTEGRATED REVIEW — COMPREHENSIVE NCLEX
PRACTICE PACK [FUNDAMENTALS,
PHARMACOLOGY, MEDICAL-SURGICAL,
MATERNITY, PEDIATRIC, EMERGENCY, AND
SPECIALTY SYSTEMS] TEST BANK
A 72-year-old post-op client with decreased LOC has
respirations 8/min, O₂ saturation 86% on room air, and snoring
respirations. What is the nurse’s priority action?
A. Call rapid response
B. Open the airway and stimulate resps; apply oxygen via bag-
valve mask if no improvement
C. Raise head of bed and reposition for comfort
D. Obtain arterial blood gases (ABG)
Answer: B.
Rationale (correct): Immediate airway support and ventilation
,are first priority for respiratory depression; bag-valve mask if
patient fails to maintain airway/oxygenation. (Safe & Effective
Care Environment; Application)
A — Incorrect: Rapid response may be indicated, but immediate
airway support precedes calling for help.
C — Incorrect: Repositioning may help partial obstruction but is
insufficient for RR 8 and sat 86%.
D — Incorrect: ABG is diagnostic and not first; treat
airway/oxygenation first.
2 (Fundamentals) — SATA
Select measures to reduce risk of catheter-associated urinary
tract infection (CAUTI):
A. Keep catheter drainage bag below bladder level
B. Routinely irrigate catheter with sterile saline every 24 hours
C. Perform hand hygiene before and after manipulation
D. Secure catheter to prevent urethral traction
E. Replace catheter every 48 hours
Answers: A, C, D.
Rationales:
A — Correct: Prevents backflow.
B — Incorrect: Routine irrigation increases infection risk; only
do if obstruction or ordered.
C — Correct: Hand hygiene prevents contamination.
D — Correct: Reduces trauma and entry of organisms.
E — Incorrect: Routine scheduled replacement is not
,recommended and can increase trauma; replace only when
indicated.
(NCLEX category: Safe & Effective Care Environment;
Application)
3 (Fundamentals) — SBA
A client with dementia wanders at night. Best evidence-based
intervention to reduce fall risk?
A. Use soft wrist restraints during night
B. Increase room lighting and use motion sensor night lights
C. Keep bed in lowest position and place mattress on floor only
when fall occurs
D. Administer a PRN sedative at bedtime
Answer: B.
Rationale (correct): Environmental modifications (lighting,
sensors) reduce wandering risks and preserve autonomy.
(Safety / Psychosocial Integrity; Analysis)
A — Incorrect: Restraints are last resort and can cause harm.
C — Incorrect: Low bed is useful but reactive; lighting addresses
wandering.
D — Incorrect: Sedatives risk over-sedation and adverse events;
nonpharmacologic interventions preferred.
4 (Fundamentals) — SBA
, Which action best demonstrates adherence to professional
boundaries?
A. Accepting small gifts from family members
B. Sharing your personal phone number with a client for after-
hours questions
C. Arranging a private social meeting with a former patient
D. Discussing the client’s medical condition with the client’s
roommate
Answer: A.
Rationale (correct): Small tokens of appreciation are often
acceptable; must follow facility policy. (Safe & Effective Care;
Evaluation)
B — Incorrect: Sharing personal contact blurs boundaries and
raises safety/privacy issues.
C — Incorrect: Socializing can breach professional boundaries.
D — Incorrect: Confidentiality violation unless roommate is
designated decision-maker.
5 (Fundamentals) — Matrix (matching)
Match the infection control term (Column A) with the correct
action (Column B).
Column A: 1. Standard precautions, 2. Contact precautions, 3.
Droplet precautions, 4. Airborne precautions
Column B: A. N95 respirator, negative-pressure room; B. Mask
