NCLEX Practice- Saunders Exam
Questions & Answers (Grade A+)
The nurse notes blanching, coolness, and edema at the peripheral
IV site. On the basis of these findings, the nurse should implement
which action?
1. remove the IV
2. apply a warm compress
3. check for blood return through the line
4. measure the area of infiltration -
correct answer ✅1. remove the IV - prevent any further damage
that may be caused by infiltration
The nurse has received the client assignments for the day. Which
client should the nurse see first?
1. the client who needs SC insulin before breakfast
2. the client who has a NG tube set on intermittent suction
3. the client who is 2 days post-op and is complaining of pain at the
incision site
4. the client with a blood glucose of 50 mg/dl and is complaining of
blurred vision -
correct answer ✅4. the client with a blood glucose of 50 mg/dl
and is complaining of blurred vision- hypoglycemia can be life
threatening, so intervene and treat this first!
,NCLEX Practice- Saunders Exam
Questions & Answers (Grade A+)
The nurse prepares to care for a client on contact precautions
admitted with MRSA. The client has an abdominal wound that
requires irrigation and has a tracheostomy that is hooked up to a
mechanical ventilator, which requires frequent suctioning. The
nurse should don which protective equipment before entering the
patient's room?
1. gloves and gown
2. gloves and face shield
3. gloves, gown, and face shield
4. gloves, gown, shoe protectors -
correct answer ✅3. gloves, gown, and face shield
The nurse is choosing age-appropriate toys for a toddler. Which toy
selection is the best choice for this age?
1. puzzle
2. toy soldiers
3. large stacking-blocks
4. card game with large pictures -
correct answer ✅3. large stacking-blocks- identify safety risks
when interacting with smaller children- choking hazards, inability to
comprehend rules, etc.
,NCLEX Practice- Saunders Exam
Questions & Answers (Grade A+)
A client diagnosed with coronary artery disease has selected guided
imagery to help cope with the psychological stress caused from the
diagnosis. Which statement made by the client indicates an
understanding of this stress reduction measure?
1. "This will help only if I play music at the same time."
2. "This will work for me only if I am alone and in a quiet area."
3. "I need to do this only when I lie down in case I fall asleep."
4. "The best thing about this is that I can use it anywhere at
anytime." -
correct answer ✅4. "The best thing about this is that I can use it
anywhere at anytime." - guided imagery involves the client creating
an image in the mind, concentrating on that image, and gradually
becoming less aware of surrounding stimuli.
A client with Parkinson's disease develops akinesia (freezing or no
movement) while ambulating, increasing the risk for falls. Which
suggestion by the nurse would cause the client to alleviate this
problem?
1. use a wheelchair when moving around
2. stand erect and use a cane while ambulating
3. keep feet close together when walking and use a walker
, NCLEX Practice- Saunders Exam
Questions & Answers (Grade A+)
4. consciously think about walking over imaginary lines on the floor
-
correct answer ✅4. consciously think about walking over
imaginary lines on the floor- clients with Parkinson's develop
bradykinesia (moving slowly) or akinesia. Having these clients
imagine lines on the floor to walk over can keep them moving
forward while remaining safe.
The nurse monitors a client receiving digoxin for which early
manifestation of digoxin toxicity?
1. anorexia
2. facial pain
3. photophobia
4. jaundice -
correct answer ✅1. anorexia- digoxin is a cardiac glycoside used to
manage/treat heart failure and A-fib. The most common early
manifestations of toxicity include GI disturbances- nausea,
vomiting, anorexia.
A MRI is ordered for a patient with a suspected brain tumor. The
nurse should implement which action to prepare the patient for
this test?
1. shave the groin for insertion of a femoral catheter
Questions & Answers (Grade A+)
The nurse notes blanching, coolness, and edema at the peripheral
IV site. On the basis of these findings, the nurse should implement
which action?
1. remove the IV
2. apply a warm compress
3. check for blood return through the line
4. measure the area of infiltration -
correct answer ✅1. remove the IV - prevent any further damage
that may be caused by infiltration
The nurse has received the client assignments for the day. Which
client should the nurse see first?
1. the client who needs SC insulin before breakfast
2. the client who has a NG tube set on intermittent suction
3. the client who is 2 days post-op and is complaining of pain at the
incision site
4. the client with a blood glucose of 50 mg/dl and is complaining of
blurred vision -
correct answer ✅4. the client with a blood glucose of 50 mg/dl
and is complaining of blurred vision- hypoglycemia can be life
threatening, so intervene and treat this first!
,NCLEX Practice- Saunders Exam
Questions & Answers (Grade A+)
The nurse prepares to care for a client on contact precautions
admitted with MRSA. The client has an abdominal wound that
requires irrigation and has a tracheostomy that is hooked up to a
mechanical ventilator, which requires frequent suctioning. The
nurse should don which protective equipment before entering the
patient's room?
1. gloves and gown
2. gloves and face shield
3. gloves, gown, and face shield
4. gloves, gown, shoe protectors -
correct answer ✅3. gloves, gown, and face shield
The nurse is choosing age-appropriate toys for a toddler. Which toy
selection is the best choice for this age?
1. puzzle
2. toy soldiers
3. large stacking-blocks
4. card game with large pictures -
correct answer ✅3. large stacking-blocks- identify safety risks
when interacting with smaller children- choking hazards, inability to
comprehend rules, etc.
,NCLEX Practice- Saunders Exam
Questions & Answers (Grade A+)
A client diagnosed with coronary artery disease has selected guided
imagery to help cope with the psychological stress caused from the
diagnosis. Which statement made by the client indicates an
understanding of this stress reduction measure?
1. "This will help only if I play music at the same time."
2. "This will work for me only if I am alone and in a quiet area."
3. "I need to do this only when I lie down in case I fall asleep."
4. "The best thing about this is that I can use it anywhere at
anytime." -
correct answer ✅4. "The best thing about this is that I can use it
anywhere at anytime." - guided imagery involves the client creating
an image in the mind, concentrating on that image, and gradually
becoming less aware of surrounding stimuli.
A client with Parkinson's disease develops akinesia (freezing or no
movement) while ambulating, increasing the risk for falls. Which
suggestion by the nurse would cause the client to alleviate this
problem?
1. use a wheelchair when moving around
2. stand erect and use a cane while ambulating
3. keep feet close together when walking and use a walker
, NCLEX Practice- Saunders Exam
Questions & Answers (Grade A+)
4. consciously think about walking over imaginary lines on the floor
-
correct answer ✅4. consciously think about walking over
imaginary lines on the floor- clients with Parkinson's develop
bradykinesia (moving slowly) or akinesia. Having these clients
imagine lines on the floor to walk over can keep them moving
forward while remaining safe.
The nurse monitors a client receiving digoxin for which early
manifestation of digoxin toxicity?
1. anorexia
2. facial pain
3. photophobia
4. jaundice -
correct answer ✅1. anorexia- digoxin is a cardiac glycoside used to
manage/treat heart failure and A-fib. The most common early
manifestations of toxicity include GI disturbances- nausea,
vomiting, anorexia.
A MRI is ordered for a patient with a suspected brain tumor. The
nurse should implement which action to prepare the patient for
this test?
1. shave the groin for insertion of a femoral catheter
