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
MEDICAL-SURGICAL (1–30) — 30 items
1. (SBA — Med-Surg)
A 68-year-old client with chronic obstructive pulmonary disease
(COPD) is admitted with increased dyspnea and a productive
cough. Pulse ox is 86% on room air, RR 28, using accessory
muscles. Which action should the nurse perform first?
A. Encourage pursed-lip breathing.
B. Start oxygen via nasal cannula at 2 L/min.
,C. Obtain a sputum specimen for culture.
D. Administer prescribed albuterol inhaler.
Answer: B. Start oxygen via nasal cannula at 2 L/min.
Rationale: Hypoxemia (SpO₂ 86%) is immediate threat — give
supplemental oxygen first (safety). Albuterol and breathing
techniques follow after oxygen. Sputum can be obtained but
not before stabilizing oxygenation. Domain: Physiological
Integrity — Reduction of Risk Potential. Cognitive level:
Application.
2. (SATA — Med-Surg)
A postoperative client (24 hrs after abdominal surgery) has an
order for morphine PRN for pain. Which actions should the
nurse take? (Select all that apply.)
A. Assess respiratory rate and sedation level before giving
morphine.
B. Give morphine and encourage the client to ambulate
immediately.
C. Use the smallest effective dose and reassess pain within 30
minutes.
D. Hold morphine if RR < 10 breaths/min and notify the
provider.
E. Offer the client a sleeping pill instead of morphine to reduce
opioid use.
,Answer: A, C, D.
Rationale: A: Must assess for respiratory depression and
sedation (safety). C: Use smallest effective dose and reassess —
good practice. D: Holding and notifying for RR <10 is correct. B
is unsafe to ambulate immediately after opioid without
assessing sedation; E is inappropriate—sleeping pill not
substitution without provider order. Domain: Safe & Effective
Care Environment (Safety); Physiological Integrity
(Pharmacological and Parenteral Therapies). Cognitive:
Application.
3. (Case cluster — Med-Surg, 3 items)
Case: 54-year-old male with heart failure (EF 30%) admitted
with increased edema, orthopnea, and weight gain. Meds
include furosemide, lisinopril, carvedilol. VS: BP 110/68, HR 88,
SpO₂ 95% RA. Daily weights show +3.2 kg in 3 days.
3a (SBA): Which assessment finding most clearly indicates fluid
overload requiring immediate intervention?
A. BP 110/68
B. Jugular venous distention (JVD) at 45°
C. SpO₂ 95% on room air
D. Heart rate 88
Answer: B. JVD at 45°.
Rationale: JVD indicates central venous pressure elevation
(volume overload) and correlates with worsening CHF. BP, HR,
, SpO₂ less specific to volume status. Domain: Physiological
Integrity — Reduction of Risk Potential. Cognitive: Analysis.
3b (SBA): The provider orders IV furosemide 40 mg now. Before
administration the nurse should:
A. Verify potassium level.
B. Check apical pulse for one full minute.
C. Start a cardiac monitor only.
D. Give medication immediately without labs.
Answer: A. Verify potassium level.
Rationale: Loop diuretics can cause hypokalemia; verify labs
and current electrolytes (safety). Cardiac monitoring may be
appropriate for severe cases but checking K+ is priority.
Domain: Physiological Integrity — Pharmacological and
Parenteral Therapies. Cognitive: Application.
3c (SBA): The nurse should prioritize patient education about:
A. Low-sodium diet and daily weight monitoring.
B. Importance of bedrest.
C. Avoiding all activity to prevent dyspnea.
D. Stopping lisinopril when edema improves.
Answer: A. Low-sodium diet and daily weight monitoring.
Rationale: These are key self-management strategies to prevent
fluid retention and early detection of decompensation. B/C
unsafe; D dangerous—ACE inhibitor should not be stopped
without orders. Domain: Health Promotion & Maintenance.
Cognitive: Application.
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
MEDICAL-SURGICAL (1–30) — 30 items
1. (SBA — Med-Surg)
A 68-year-old client with chronic obstructive pulmonary disease
(COPD) is admitted with increased dyspnea and a productive
cough. Pulse ox is 86% on room air, RR 28, using accessory
muscles. Which action should the nurse perform first?
A. Encourage pursed-lip breathing.
B. Start oxygen via nasal cannula at 2 L/min.
,C. Obtain a sputum specimen for culture.
D. Administer prescribed albuterol inhaler.
Answer: B. Start oxygen via nasal cannula at 2 L/min.
Rationale: Hypoxemia (SpO₂ 86%) is immediate threat — give
supplemental oxygen first (safety). Albuterol and breathing
techniques follow after oxygen. Sputum can be obtained but
not before stabilizing oxygenation. Domain: Physiological
Integrity — Reduction of Risk Potential. Cognitive level:
Application.
2. (SATA — Med-Surg)
A postoperative client (24 hrs after abdominal surgery) has an
order for morphine PRN for pain. Which actions should the
nurse take? (Select all that apply.)
A. Assess respiratory rate and sedation level before giving
morphine.
B. Give morphine and encourage the client to ambulate
immediately.
C. Use the smallest effective dose and reassess pain within 30
minutes.
D. Hold morphine if RR < 10 breaths/min and notify the
provider.
E. Offer the client a sleeping pill instead of morphine to reduce
opioid use.
,Answer: A, C, D.
Rationale: A: Must assess for respiratory depression and
sedation (safety). C: Use smallest effective dose and reassess —
good practice. D: Holding and notifying for RR <10 is correct. B
is unsafe to ambulate immediately after opioid without
assessing sedation; E is inappropriate—sleeping pill not
substitution without provider order. Domain: Safe & Effective
Care Environment (Safety); Physiological Integrity
(Pharmacological and Parenteral Therapies). Cognitive:
Application.
3. (Case cluster — Med-Surg, 3 items)
Case: 54-year-old male with heart failure (EF 30%) admitted
with increased edema, orthopnea, and weight gain. Meds
include furosemide, lisinopril, carvedilol. VS: BP 110/68, HR 88,
SpO₂ 95% RA. Daily weights show +3.2 kg in 3 days.
3a (SBA): Which assessment finding most clearly indicates fluid
overload requiring immediate intervention?
A. BP 110/68
B. Jugular venous distention (JVD) at 45°
C. SpO₂ 95% on room air
D. Heart rate 88
Answer: B. JVD at 45°.
Rationale: JVD indicates central venous pressure elevation
(volume overload) and correlates with worsening CHF. BP, HR,
, SpO₂ less specific to volume status. Domain: Physiological
Integrity — Reduction of Risk Potential. Cognitive: Analysis.
3b (SBA): The provider orders IV furosemide 40 mg now. Before
administration the nurse should:
A. Verify potassium level.
B. Check apical pulse for one full minute.
C. Start a cardiac monitor only.
D. Give medication immediately without labs.
Answer: A. Verify potassium level.
Rationale: Loop diuretics can cause hypokalemia; verify labs
and current electrolytes (safety). Cardiac monitoring may be
appropriate for severe cases but checking K+ is priority.
Domain: Physiological Integrity — Pharmacological and
Parenteral Therapies. Cognitive: Application.
3c (SBA): The nurse should prioritize patient education about:
A. Low-sodium diet and daily weight monitoring.
B. Importance of bedrest.
C. Avoiding all activity to prevent dyspnea.
D. Stopping lisinopril when edema improves.
Answer: A. Low-sodium diet and daily weight monitoring.
Rationale: These are key self-management strategies to prevent
fluid retention and early detection of decompensation. B/C
unsafe; D dangerous—ACE inhibitor should not be stopped
without orders. Domain: Health Promotion & Maintenance.
Cognitive: Application.
