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 (18 items: 12 standalone + 6 in Case Study A)
1. (SBA — Fundamentals / Physiological Integrity —
Application)
A postoperative client on PCA reports sedation and RR 8
breaths/min. Priority nursing action?
A. Encourage deep breathing and ambulation.
B. Administer naloxone per protocol.
C. Decrease PCA dose and notify provider.
D. Place oxygen saturation probe and continue to monitor.
, Answer: B. Administer naloxone per protocol.
Rationale:
• B (Correct): RR 8 indicates opioid-induced respiratory
depression — naloxone reverses life-threatening opioid
effect quickly (evaluate and act).
• A (Incorrect): Deep breathing/ambulation are appropriate
later but not for acute respiratory depression.
• C (Incorrect): Decreasing dose may be appropriate, but
immediate reversal is higher priority.
• D (Incorrect): Monitoring is necessary but not the
immediate corrective action for RR 8.
Domain: Physiological Integrity — Reduction of Risk
Potential.
Cognitive level: Evaluation.
2. (SATA — Fundamentals / Safe & Effective Care
Environment — Analysis)
Which actions should nurse include when delegating
routine medication administration to an experienced LPN?
(Select all that apply.)
A. Confirm LPN has competency for the specific meds.
B. Delegate initial nursing assessment of a newly admitted
unstable client.
C. Provide clear expected outcomes and timeframes.
D. Remain available for consultation and accept
accountability.
, E. Delegate IV push morphine to LPN in all states.
Answer: A, C, D.
Rationale:
• A (Correct): Delegate only within the delegatee’s
competency.
• B (Incorrect): Initial assessment of unstable/new client is
RN responsibility.
• C (Correct): Clear outcomes/timeframes required for safe
delegation.
• D (Correct): RN retains accountability; must be available.
• E (Incorrect): Scope varies by state and med; cannot
blanket-delegate controlled IV push.
Domain: Safe & Effective Care Environment —
Management of Care.
Cognitive level: Analysis.
3. (SBA — Fundamentals / Physiological Integrity —
Application)
A client with stage II pressure injury receives wound
packing. Appropriate frequency for dressing change if
using saline-moistened gauze and moderate drainage?
A. Every 12–24 hours.
B. Every 3–5 days.
C. Once weekly.
D. Only when soiled.
, Answer: A. Every 12–24 hours.
Rationale:
• A (Correct): Moderate drainage with packing typically
requires daily or twice-daily changes to prevent infection.
• B/C/D (Incorrect): Too infrequent for moderate drainage;
risk of maceration/infection.
Domain: Physiological Integrity — Basic Care & Comfort.
Cognitive level: Application.
4. (SBA — Fundamentals / Health Promotion — Application)
A college clinic nurse counsels a 20-yr-old about self-breast
exam timing. Best instruction?
A. Monthly on the first day of the month.
B. Monthly 5–7 days after onset of menses.
C. Weekly on Sunday.
D. Only if a lump is felt.
Answer: B. Monthly 5–7 days after onset of menses.
Rationale:
• B (Correct): Least breast tenderness and most consistent
timing.
• A/C/D (Incorrect): Not tied to hormonal fluctuations or are
reactive-only.
Domain: Health Promotion & Maintenance.
Cognitive level: Application.
5. (SBA — Fundamentals / Safe & Effective Care —
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
FUNDAMENTALS (18 items: 12 standalone + 6 in Case Study A)
1. (SBA — Fundamentals / Physiological Integrity —
Application)
A postoperative client on PCA reports sedation and RR 8
breaths/min. Priority nursing action?
A. Encourage deep breathing and ambulation.
B. Administer naloxone per protocol.
C. Decrease PCA dose and notify provider.
D. Place oxygen saturation probe and continue to monitor.
, Answer: B. Administer naloxone per protocol.
Rationale:
• B (Correct): RR 8 indicates opioid-induced respiratory
depression — naloxone reverses life-threatening opioid
effect quickly (evaluate and act).
• A (Incorrect): Deep breathing/ambulation are appropriate
later but not for acute respiratory depression.
• C (Incorrect): Decreasing dose may be appropriate, but
immediate reversal is higher priority.
• D (Incorrect): Monitoring is necessary but not the
immediate corrective action for RR 8.
Domain: Physiological Integrity — Reduction of Risk
Potential.
Cognitive level: Evaluation.
2. (SATA — Fundamentals / Safe & Effective Care
Environment — Analysis)
Which actions should nurse include when delegating
routine medication administration to an experienced LPN?
(Select all that apply.)
A. Confirm LPN has competency for the specific meds.
B. Delegate initial nursing assessment of a newly admitted
unstable client.
C. Provide clear expected outcomes and timeframes.
D. Remain available for consultation and accept
accountability.
, E. Delegate IV push morphine to LPN in all states.
Answer: A, C, D.
Rationale:
• A (Correct): Delegate only within the delegatee’s
competency.
• B (Incorrect): Initial assessment of unstable/new client is
RN responsibility.
• C (Correct): Clear outcomes/timeframes required for safe
delegation.
• D (Correct): RN retains accountability; must be available.
• E (Incorrect): Scope varies by state and med; cannot
blanket-delegate controlled IV push.
Domain: Safe & Effective Care Environment —
Management of Care.
Cognitive level: Analysis.
3. (SBA — Fundamentals / Physiological Integrity —
Application)
A client with stage II pressure injury receives wound
packing. Appropriate frequency for dressing change if
using saline-moistened gauze and moderate drainage?
A. Every 12–24 hours.
B. Every 3–5 days.
C. Once weekly.
D. Only when soiled.
, Answer: A. Every 12–24 hours.
Rationale:
• A (Correct): Moderate drainage with packing typically
requires daily or twice-daily changes to prevent infection.
• B/C/D (Incorrect): Too infrequent for moderate drainage;
risk of maceration/infection.
Domain: Physiological Integrity — Basic Care & Comfort.
Cognitive level: Application.
4. (SBA — Fundamentals / Health Promotion — Application)
A college clinic nurse counsels a 20-yr-old about self-breast
exam timing. Best instruction?
A. Monthly on the first day of the month.
B. Monthly 5–7 days after onset of menses.
C. Weekly on Sunday.
D. Only if a lump is felt.
Answer: B. Monthly 5–7 days after onset of menses.
Rationale:
• B (Correct): Least breast tenderness and most consistent
timing.
• A/C/D (Incorrect): Not tied to hormonal fluctuations or are
reactive-only.
Domain: Health Promotion & Maintenance.
Cognitive level: Application.
5. (SBA — Fundamentals / Safe & Effective Care —
Application)
