Test Bank for Saunders Comprehensive
Review for the NCLEX-RN® Examination,
9th Edition by Linda Anne Silvestri and
Angela Silvestri – Complete Questions
and Answers (Pass Guaranteed) ||
Updated 2025
Section 1: Safe and Effective Care Environment / Nursing Process
Q1: The nurse enters a client’s room and finds a small fire on the bedside table. What is
the first action?
a) Attempt to extinguish the fire with water
b) Remove the client from the room
c) Activate the fire alarm
d) Call the physician
Answer: b) Remove the client from the room
Rationale: In fire safety (RACE: Rescue, Alarm, Contain, Extinguish), the first step is to
rescue/remove anyone in immediate danger.
Q2: During the planning phase of the nursing process, the nurse:
a) Collects baseline data
b) Establishes measurable goals and outcomes
c) Administers medications
d) Evaluates patient responses
Answer: b) Establishes measurable goals and outcomes
Rationale: Planning sets specific objectives to guide interventions and evaluation.
Q3: A nurse delegates a task to a UAP. Which task is appropriate?
a) Administering oral medications
b) Measuring vital signs on a stable patient
,c) Performing a wound assessment
d) Initiating IV therapy
Answer: b) Measuring vital signs on a stable patient
Rationale: UAPs can perform routine tasks for stable clients; assessment and
medication administration are nursing responsibilities.
Q4: A client refuses a prescribed procedure. The nurse should:
a) Force the client to comply
b) Notify the physician immediately
c) Document the refusal and provide education
d) Ignore the refusal
Answer: c) Document the refusal and provide education
Rationale: Respect for patient autonomy requires education, documentation, and
communication without coercion.
Q5: When using SBAR to communicate with a physician, the "A" stands for:
a) Assessment
b) Analysis
c) Action
d) Alert
Answer: a) Assessment
Rationale: SBAR: Situation, Background, Assessment, Recommendation – structured
communication tool for safety.
Section 2: Health Promotion and Maintenance
Q6: A nurse teaching about healthy nutrition includes:
a) High intake of saturated fats
b) Increased fiber and whole grains
c) Excessive sugar consumption
d) Minimal water intake
Answer: b) Increased fiber and whole grains
Rationale: Promotes bowel health, lowers cholesterol, and supports overall wellness.
Q7: Which vaccine is contraindicated during pregnancy?
a) Influenza (inactivated)
b) Tdap
c) MMR
d) Hepatitis B
, Answer: c) MMR
Rationale: Live vaccines (like MMR) are contraindicated in pregnancy due to risk to the
fetus.
Q8: A client at 28 weeks gestation asks about fetal movement counting. The nurse
instructs:
a) Count fetal movements once a week
b) Expect decreased movement after meals
c) Track at the same time each day and report decreased movement
d) Count only when feeling unwell
Answer: c) Track at the same time each day and report decreased movement
Rationale: Consistent daily monitoring helps detect potential fetal compromise.
Q9: Early signs of dehydration in an infant include:
a) Weight gain, moist mucous membranes
b) Sunken fontanel, dry mouth, decreased urine output
c) Fever and vomiting
d) Increased appetite and activity
Answer: b) Sunken fontanel, dry mouth, decreased urine output
Rationale: These are classic indicators of fluid deficit in infants.
Q10: Screening for hypertension in adults should begin:
a) At age 18
b) At age 30
c) Only if symptoms occur
d) At age 50
Answer: a) At age 18
Rationale: Early detection prevents long-term cardiovascular complications.
Section 3: Psychosocial Integrity
Q11: A client exhibits angry outbursts in the unit. The nurse’s first intervention should
be:
a) Restrain immediately
b) Ignore the behavior
c) Approach calmly and set limits
d) Call security
Answer: c) Approach calmly and set limits
Rationale: Initial de-escalation promotes safety and therapeutic communication.
Review for the NCLEX-RN® Examination,
9th Edition by Linda Anne Silvestri and
Angela Silvestri – Complete Questions
and Answers (Pass Guaranteed) ||
Updated 2025
Section 1: Safe and Effective Care Environment / Nursing Process
Q1: The nurse enters a client’s room and finds a small fire on the bedside table. What is
the first action?
a) Attempt to extinguish the fire with water
b) Remove the client from the room
c) Activate the fire alarm
d) Call the physician
Answer: b) Remove the client from the room
Rationale: In fire safety (RACE: Rescue, Alarm, Contain, Extinguish), the first step is to
rescue/remove anyone in immediate danger.
Q2: During the planning phase of the nursing process, the nurse:
a) Collects baseline data
b) Establishes measurable goals and outcomes
c) Administers medications
d) Evaluates patient responses
Answer: b) Establishes measurable goals and outcomes
Rationale: Planning sets specific objectives to guide interventions and evaluation.
Q3: A nurse delegates a task to a UAP. Which task is appropriate?
a) Administering oral medications
b) Measuring vital signs on a stable patient
,c) Performing a wound assessment
d) Initiating IV therapy
Answer: b) Measuring vital signs on a stable patient
Rationale: UAPs can perform routine tasks for stable clients; assessment and
medication administration are nursing responsibilities.
Q4: A client refuses a prescribed procedure. The nurse should:
a) Force the client to comply
b) Notify the physician immediately
c) Document the refusal and provide education
d) Ignore the refusal
Answer: c) Document the refusal and provide education
Rationale: Respect for patient autonomy requires education, documentation, and
communication without coercion.
Q5: When using SBAR to communicate with a physician, the "A" stands for:
a) Assessment
b) Analysis
c) Action
d) Alert
Answer: a) Assessment
Rationale: SBAR: Situation, Background, Assessment, Recommendation – structured
communication tool for safety.
Section 2: Health Promotion and Maintenance
Q6: A nurse teaching about healthy nutrition includes:
a) High intake of saturated fats
b) Increased fiber and whole grains
c) Excessive sugar consumption
d) Minimal water intake
Answer: b) Increased fiber and whole grains
Rationale: Promotes bowel health, lowers cholesterol, and supports overall wellness.
Q7: Which vaccine is contraindicated during pregnancy?
a) Influenza (inactivated)
b) Tdap
c) MMR
d) Hepatitis B
, Answer: c) MMR
Rationale: Live vaccines (like MMR) are contraindicated in pregnancy due to risk to the
fetus.
Q8: A client at 28 weeks gestation asks about fetal movement counting. The nurse
instructs:
a) Count fetal movements once a week
b) Expect decreased movement after meals
c) Track at the same time each day and report decreased movement
d) Count only when feeling unwell
Answer: c) Track at the same time each day and report decreased movement
Rationale: Consistent daily monitoring helps detect potential fetal compromise.
Q9: Early signs of dehydration in an infant include:
a) Weight gain, moist mucous membranes
b) Sunken fontanel, dry mouth, decreased urine output
c) Fever and vomiting
d) Increased appetite and activity
Answer: b) Sunken fontanel, dry mouth, decreased urine output
Rationale: These are classic indicators of fluid deficit in infants.
Q10: Screening for hypertension in adults should begin:
a) At age 18
b) At age 30
c) Only if symptoms occur
d) At age 50
Answer: a) At age 18
Rationale: Early detection prevents long-term cardiovascular complications.
Section 3: Psychosocial Integrity
Q11: A client exhibits angry outbursts in the unit. The nurse’s first intervention should
be:
a) Restrain immediately
b) Ignore the behavior
c) Approach calmly and set limits
d) Call security
Answer: c) Approach calmly and set limits
Rationale: Initial de-escalation promotes safety and therapeutic communication.
