Saunders Comprehensive NCLEX
Review (5th Ed.) Exam Questions &
Answers (Grade A+)
S. A nurse notes blanching, coolness, and edema at the peripheral
intravenous (IV) site. Based on these findings, the nurse
implements which action?
a. Discontinues the IV
b. Applies a warm compress
c. Checks for a blood return
d. Measures the area of infiltration -
correct answer ✅a
(This question requires that you focus on the data identified in the
question and determine that the client is experiencing an
infiltration. Next you need to consider the harmful effects of
infiltration and determine the action to implement. Because
infiltration can be damaging to the surrounding tissue, the most
appropriate action is to discontinue the IV to prevent any further
damage.)
,Saunders Comprehensive NCLEX
Review (5th Ed.) Exam Questions &
Answers (Grade A+)
S. A nurse has received the client assignment for the day. Which
client should the nurse assess first?
a. The client who has a nasogastric tube attached to intermittent
suction
b. The client who needs to receive subcutaneous insulin before
breakfast
c. The client who is 2 days postoperative and is complaining of
incisional pain
d. The client who has a blood glucose level of 50 mg/dL and
complaints of blurred vision -
correct answer ✅d
(This question requires you to establish priorities by comparing the
needs of each client and deciding which need is urgent. The client
described in option 4 has a blood glucose level and symptoms
reflective of hypoglycemia. This client should be assessed first so
that treatment can be implemented. Although the clients in options
,Saunders Comprehensive NCLEX
Review (5th Ed.) Exam Questions &
Answers (Grade A+)
1, 2, and 3 have needs that require assessment, they are not a
priority and can wait until the client in option 4 is stabilized.)
S. A nurse prepares to care for a client on contact precautions who
has a hospital-acquired infection caused by methicillin-resistant
Staphylococcus aureus (MRSA). The client has an abdominal wound
that requires irrigation and has a tracheostomy attached to a
mechanical ventilator, which requires frequent suctioning. The
nurse assembles which of the following necessary protective items
before entering the client's room?
a. Gloves and a gown
b. Gloves, mask, and goggles
c. Gloves, mask, gown, and goggles
d. Gloves, gown, and shoe protectors -
correct answer ✅c
, Saunders Comprehensive NCLEX
Review (5th Ed.) Exam Questions &
Answers (Grade A+)
(This question addresses content related to protecting oneself from
contracting an infection and requires that you consider the
methods of possible transmission of infection, based on the client's
condition. Because splashes of infective material can occur during
the wound irrigation or suctioning of the tracheostomy, option 3 is
correct.)
S. The nurse is choosing age-appropriate toys for a toddler. Which
of the following would be the best toy?
a. Puzzle
b. Toy soldiers
c. Large stacking blocks
d. A card game with large pictures -
correct answer ✅c
Review (5th Ed.) Exam Questions &
Answers (Grade A+)
S. A nurse notes blanching, coolness, and edema at the peripheral
intravenous (IV) site. Based on these findings, the nurse
implements which action?
a. Discontinues the IV
b. Applies a warm compress
c. Checks for a blood return
d. Measures the area of infiltration -
correct answer ✅a
(This question requires that you focus on the data identified in the
question and determine that the client is experiencing an
infiltration. Next you need to consider the harmful effects of
infiltration and determine the action to implement. Because
infiltration can be damaging to the surrounding tissue, the most
appropriate action is to discontinue the IV to prevent any further
damage.)
,Saunders Comprehensive NCLEX
Review (5th Ed.) Exam Questions &
Answers (Grade A+)
S. A nurse has received the client assignment for the day. Which
client should the nurse assess first?
a. The client who has a nasogastric tube attached to intermittent
suction
b. The client who needs to receive subcutaneous insulin before
breakfast
c. The client who is 2 days postoperative and is complaining of
incisional pain
d. The client who has a blood glucose level of 50 mg/dL and
complaints of blurred vision -
correct answer ✅d
(This question requires you to establish priorities by comparing the
needs of each client and deciding which need is urgent. The client
described in option 4 has a blood glucose level and symptoms
reflective of hypoglycemia. This client should be assessed first so
that treatment can be implemented. Although the clients in options
,Saunders Comprehensive NCLEX
Review (5th Ed.) Exam Questions &
Answers (Grade A+)
1, 2, and 3 have needs that require assessment, they are not a
priority and can wait until the client in option 4 is stabilized.)
S. A nurse prepares to care for a client on contact precautions who
has a hospital-acquired infection caused by methicillin-resistant
Staphylococcus aureus (MRSA). The client has an abdominal wound
that requires irrigation and has a tracheostomy attached to a
mechanical ventilator, which requires frequent suctioning. The
nurse assembles which of the following necessary protective items
before entering the client's room?
a. Gloves and a gown
b. Gloves, mask, and goggles
c. Gloves, mask, gown, and goggles
d. Gloves, gown, and shoe protectors -
correct answer ✅c
, Saunders Comprehensive NCLEX
Review (5th Ed.) Exam Questions &
Answers (Grade A+)
(This question addresses content related to protecting oneself from
contracting an infection and requires that you consider the
methods of possible transmission of infection, based on the client's
condition. Because splashes of infective material can occur during
the wound irrigation or suctioning of the tracheostomy, option 3 is
correct.)
S. The nurse is choosing age-appropriate toys for a toddler. Which
of the following would be the best toy?
a. Puzzle
b. Toy soldiers
c. Large stacking blocks
d. A card game with large pictures -
correct answer ✅c
