Saunders NCLEX Exam Questions &
Answers (Grade A+)
The nurse is assessing a client's postoperative pain using the
PQRSTU method. Using this method, which questions would the
nurse ask the client? -
correct answer ✅The PQRSTU method is one method of assessing
pain. With this method, the nurse asks about the following:
Precipitating factors (option 6); Quality of the pain (option 3);
Region or Radiation of the pain (option 1); Severity of the pain;
Timing of the pain (continuous or intermittent); and How the pain
affects you (option 4). Options 2 and 5 may be questions that would
be asked; however, these are not a part of the PQRSTU method.
The nurse is preparing to administer furosemide (Lasix) to a client
with a diagnosis of heart failure. Which is the most important
laboratory test result for the nurse to check before administering
this medication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level -
correct answer ✅Furosemide is a loop diuretic. The medication
causes a decrease in the client's electrolytes, especially potassium,
sodium, and chloride. Administering furosemide to a client with low
,Saunders NCLEX Exam Questions &
Answers (Grade A+)
electrolyte levels could precipitate ventricular dysrhythmias.
Options 1 and 4 reflect renal function. The cholesterol level is
unrelated to the administration of this medication.
A nurse caring for a client with a diagnosis of gastrointestinal (GI)
bleeding reviews the client's laboratory results and notes a
hematocrit level of 30%. Which action should the nurse take?
1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record. -
correct answer ✅1-Report the abnormally low level.
The normal hematocrit level in a male ranges from 42% to 52%, and
35% to 47 % in a female, depending on age. A hematocrit level of
30% is a low level and would be reported to the health care
provider because it indicates blood loss; therefore options 2, 3, and
4 are incorrect.
,Saunders NCLEX Exam Questions &
Answers (Grade A+)
A nurse provides dietary instructions to a client who will be taking
warfarin sodium (Coumadin). The nurse should tell the client to
avoid which food item?
1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese -
correct answer ✅2-Spinach
Warfarin sodium is an anticoagulant. Anticoagulant medications act
by antagonizing the action of vitamin K, which is needed for
clotting. When a client is taking an anticoagulant, foods high in
vitamin K often are omitted from the diet. Vitamin K-rich foods
include green leafy vegetables, fish, liver, coffee, and tea.
A client who has been receiving total parenteral nutrition (TPN) by
way of a central venous access device complains of chest pain and
dyspnea. The nurse quickly assesses the client's vital signs and
notes that the pulse rate has increased and the blood pressure has
dropped. The nurse determines that the client is most likely
experiencing which problem?
, Saunders NCLEX Exam Questions &
Answers (Grade A+)
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance -
correct answer ✅2-Air embolism
The signs and symptoms of air embolism include chest pain,
dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse
also may hear a loud churning sound over the pericardium on
auscultation of the client's chest. The signs and symptoms of sepsis
include fever, chills, and general malaise. Fluid overload causes
increased intravascular volume, which increases the blood pressure
and the pulse rate as the heart tries to pump the extra fluid
volume. Fluid overload also causes neck vein distention and shifting
of fluid into the alveoli, resulting in lung crackles. The signs and
symptoms of a fluid imbalance depend on the type of imbalance
the client is experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of
burning and a feeling of tightness at the IV insertion site. On
assessment, the nurse detects coolness and swelling at the site and
notes that the IV rate has slowed. The nurse determines that which
Answers (Grade A+)
The nurse is assessing a client's postoperative pain using the
PQRSTU method. Using this method, which questions would the
nurse ask the client? -
correct answer ✅The PQRSTU method is one method of assessing
pain. With this method, the nurse asks about the following:
Precipitating factors (option 6); Quality of the pain (option 3);
Region or Radiation of the pain (option 1); Severity of the pain;
Timing of the pain (continuous or intermittent); and How the pain
affects you (option 4). Options 2 and 5 may be questions that would
be asked; however, these are not a part of the PQRSTU method.
The nurse is preparing to administer furosemide (Lasix) to a client
with a diagnosis of heart failure. Which is the most important
laboratory test result for the nurse to check before administering
this medication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level -
correct answer ✅Furosemide is a loop diuretic. The medication
causes a decrease in the client's electrolytes, especially potassium,
sodium, and chloride. Administering furosemide to a client with low
,Saunders NCLEX Exam Questions &
Answers (Grade A+)
electrolyte levels could precipitate ventricular dysrhythmias.
Options 1 and 4 reflect renal function. The cholesterol level is
unrelated to the administration of this medication.
A nurse caring for a client with a diagnosis of gastrointestinal (GI)
bleeding reviews the client's laboratory results and notes a
hematocrit level of 30%. Which action should the nurse take?
1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record. -
correct answer ✅1-Report the abnormally low level.
The normal hematocrit level in a male ranges from 42% to 52%, and
35% to 47 % in a female, depending on age. A hematocrit level of
30% is a low level and would be reported to the health care
provider because it indicates blood loss; therefore options 2, 3, and
4 are incorrect.
,Saunders NCLEX Exam Questions &
Answers (Grade A+)
A nurse provides dietary instructions to a client who will be taking
warfarin sodium (Coumadin). The nurse should tell the client to
avoid which food item?
1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese -
correct answer ✅2-Spinach
Warfarin sodium is an anticoagulant. Anticoagulant medications act
by antagonizing the action of vitamin K, which is needed for
clotting. When a client is taking an anticoagulant, foods high in
vitamin K often are omitted from the diet. Vitamin K-rich foods
include green leafy vegetables, fish, liver, coffee, and tea.
A client who has been receiving total parenteral nutrition (TPN) by
way of a central venous access device complains of chest pain and
dyspnea. The nurse quickly assesses the client's vital signs and
notes that the pulse rate has increased and the blood pressure has
dropped. The nurse determines that the client is most likely
experiencing which problem?
, Saunders NCLEX Exam Questions &
Answers (Grade A+)
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance -
correct answer ✅2-Air embolism
The signs and symptoms of air embolism include chest pain,
dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse
also may hear a loud churning sound over the pericardium on
auscultation of the client's chest. The signs and symptoms of sepsis
include fever, chills, and general malaise. Fluid overload causes
increased intravascular volume, which increases the blood pressure
and the pulse rate as the heart tries to pump the extra fluid
volume. Fluid overload also causes neck vein distention and shifting
of fluid into the alveoli, resulting in lung crackles. The signs and
symptoms of a fluid imbalance depend on the type of imbalance
the client is experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of
burning and a feeling of tightness at the IV insertion site. On
assessment, the nurse detects coolness and swelling at the site and
notes that the IV rate has slowed. The nurse determines that which
