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
Fundamentals — 15 items
1. (SBA — Fundamentals / SECE) A postoperative client with
PCA (patient-controlled analgesia) reports increased
sedation and RR 8/min. What is the nurse’s best first
action?
A. Administer naloxone.
B. Stop the PCA infusion and stimulate the client.
C. Call the physician to reduce the PCA dose.
D. Document findings and continue monitoring.
,Answer: B. Stop the PCA infusion and stimulate the client.
Rationales:
A. Administer naloxone — not first; naloxone is for severe
respiratory depression after other immediate measures;
requires assessment. (PI)
B. Stop the PCA infusion and stimulate — correct; immediate
action to protect airway and reverse oversedation while
preparing further measures. (SECE/PI)
C. Call physician to reduce dose — inappropriate as first step
because client is breathing inadequately now. (SECE)
D. Document and continue — unsafe; delayed action risks
hypoventilation. (SECE)
2. (SATA — Fundamentals / SECE) Which actions should the
nurse include when establishing a sterile field? (Select all
that apply.)
A. Open sterile package with the top flap away from body.
B. Keep sterile gloved hands above waist level.
C. Turn back when reaching across sterile field.
D. Add sterile items by holding them 6 inches above the
field.
E. Don sterile gloves before opening sterile supplies.
Answer: A, B, D.
Rationales:
A. Open top flap away — correct; prevents contaminating the
field. (SECE)
B. Keep sterile hands above waist — correct; below waist is
,considered contaminated. (SECE)
C. Turn back when reaching across — incorrect; turning back
may contaminate field. (SECE)
D. Hold items 6 inches above — correct; reduces risk of
contamination. (SECE)
E. Don gloves before opening supplies — incorrect sequence;
open supplies first, then glove to avoid contaminating gloves.
(SECE)
3. (SBA — Fundamentals / PI) A client with a peripheral IV
reports pain and swelling at the site. The IV infusion is
infusing normally. Best action?
A. Apply warm compress and continue infusion.
B. Stop infusion, remove IV, and restart in other extremity.
C. Slow infusion rate and elevate extremity.
D. Flush IV with 10 mL saline to ensure patency.
Answer: B. Stop infusion, remove IV, and restart in other
extremity.
Rationales:
A. Warm compress — may be used for infiltration after stopping
infusion, but continuing infusion is unsafe. (SECE/PI)
B. Stop/remove and restart — correct; signs of
infiltration/phlebitis require stopping and removing to prevent
tissue injury. (SECE/PI)
C. Slow infusion — inadequate; does not address infiltration.
(SECE)
, D. Flush with 10 mL — flushing into an infiltrated site can
worsen extravasation. (SECE/PI)
4. (SBA — Fundamentals / HPM) Which vaccine is
recommended for a pregnant client during each pregnancy
to protect newborn from pertussis?
A. MMR
B. Tdap
C. Varicella
D. Hep B
Answer: B. Tdap.
Rationales:
A. MMR — contraindicated in pregnancy (live vaccine). (HPM)
B. Tdap — correct; recommended during each pregnancy (27–
36 weeks) to protect infant. (HPM)
C. Varicella — contraindicated in pregnancy if nonimmune.
(HPM)
D. Hep B — given based on maternal risk, not routinely each
pregnancy. (HPM)
5. (SATA — Fundamentals / PSY) A client with moderate
anxiety is pacing and speaking rapidly. Which nursing
interventions are appropriate? (Select all that apply.)
A. Sit with the client and use calm voice.
B. Encourage client to discuss all life stressors in detail.
C. Offer simple, clear instructions.
D. Provide a quiet room and limit stimuli.
E. Tell the client to stop worrying as it’s unhelpful.
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
Fundamentals — 15 items
1. (SBA — Fundamentals / SECE) A postoperative client with
PCA (patient-controlled analgesia) reports increased
sedation and RR 8/min. What is the nurse’s best first
action?
A. Administer naloxone.
B. Stop the PCA infusion and stimulate the client.
C. Call the physician to reduce the PCA dose.
D. Document findings and continue monitoring.
,Answer: B. Stop the PCA infusion and stimulate the client.
Rationales:
A. Administer naloxone — not first; naloxone is for severe
respiratory depression after other immediate measures;
requires assessment. (PI)
B. Stop the PCA infusion and stimulate — correct; immediate
action to protect airway and reverse oversedation while
preparing further measures. (SECE/PI)
C. Call physician to reduce dose — inappropriate as first step
because client is breathing inadequately now. (SECE)
D. Document and continue — unsafe; delayed action risks
hypoventilation. (SECE)
2. (SATA — Fundamentals / SECE) Which actions should the
nurse include when establishing a sterile field? (Select all
that apply.)
A. Open sterile package with the top flap away from body.
B. Keep sterile gloved hands above waist level.
C. Turn back when reaching across sterile field.
D. Add sterile items by holding them 6 inches above the
field.
E. Don sterile gloves before opening sterile supplies.
Answer: A, B, D.
Rationales:
A. Open top flap away — correct; prevents contaminating the
field. (SECE)
B. Keep sterile hands above waist — correct; below waist is
,considered contaminated. (SECE)
C. Turn back when reaching across — incorrect; turning back
may contaminate field. (SECE)
D. Hold items 6 inches above — correct; reduces risk of
contamination. (SECE)
E. Don gloves before opening supplies — incorrect sequence;
open supplies first, then glove to avoid contaminating gloves.
(SECE)
3. (SBA — Fundamentals / PI) A client with a peripheral IV
reports pain and swelling at the site. The IV infusion is
infusing normally. Best action?
A. Apply warm compress and continue infusion.
B. Stop infusion, remove IV, and restart in other extremity.
C. Slow infusion rate and elevate extremity.
D. Flush IV with 10 mL saline to ensure patency.
Answer: B. Stop infusion, remove IV, and restart in other
extremity.
Rationales:
A. Warm compress — may be used for infiltration after stopping
infusion, but continuing infusion is unsafe. (SECE/PI)
B. Stop/remove and restart — correct; signs of
infiltration/phlebitis require stopping and removing to prevent
tissue injury. (SECE/PI)
C. Slow infusion — inadequate; does not address infiltration.
(SECE)
, D. Flush with 10 mL — flushing into an infiltrated site can
worsen extravasation. (SECE/PI)
4. (SBA — Fundamentals / HPM) Which vaccine is
recommended for a pregnant client during each pregnancy
to protect newborn from pertussis?
A. MMR
B. Tdap
C. Varicella
D. Hep B
Answer: B. Tdap.
Rationales:
A. MMR — contraindicated in pregnancy (live vaccine). (HPM)
B. Tdap — correct; recommended during each pregnancy (27–
36 weeks) to protect infant. (HPM)
C. Varicella — contraindicated in pregnancy if nonimmune.
(HPM)
D. Hep B — given based on maternal risk, not routinely each
pregnancy. (HPM)
5. (SATA — Fundamentals / PSY) A client with moderate
anxiety is pacing and speaking rapidly. Which nursing
interventions are appropriate? (Select all that apply.)
A. Sit with the client and use calm voice.
B. Encourage client to discuss all life stressors in detail.
C. Offer simple, clear instructions.
D. Provide a quiet room and limit stimuli.
E. Tell the client to stop worrying as it’s unhelpful.
