Test Bank for Saunders Comprehensive
Review for the NCLEX-RN® Examination,
9th Edition by Linda Anne Silvestri and
Angela Silvestri – Complete Questions
and Answers (Pass Guaranteed) ||
Updated 2025
1. A nurse is caring for a client with heart failure who has 3+ pitting edema.
Which nursing intervention is the highest priority?
A. Encourage ambulation
B. Elevate the legs
C. Administer diuretics as prescribed
D. Restrict fluid intake
Answer: C
Rationale: Diuretics help remove excess fluid and reduce edema, directly addressing the
underlying pathophysiology. Elevating legs is supportive but not the highest priority.
2. A client with diabetes mellitus has a blood glucose of 320 mg/dL and
fruity breath. Which complication is most likely?
A. Hypoglycemia
B. Diabetic ketoacidosis (DKA)
C. Hyperosmolar hyperglycemic state (HHS)
D. Insulin shock
Answer: B
Rationale: Hyperglycemia with fruity breath and polyuria suggests DKA, a complication
of uncontrolled type 1 diabetes.
,3. Which of the following is the most appropriate action for a nurse caring
for a client who suddenly develops shortness of breath and wheezing after
taking penicillin?
A. Document the reaction
B. Administer an antihistamine
C. Withhold the next dose
D. Call for emergency assistance
Answer: D
Rationale: Sudden wheezing after penicillin indicates a possible anaphylactic reaction,
which is life-threatening. Emergency intervention is required.
4. The nurse is teaching a client with COPD about pursed-lip breathing.
Which statement by the client indicates understanding?
A. “I inhale quickly through my mouth and exhale through my nose.”
B. “I exhale slowly through pursed lips.”
C. “I hold my breath as long as possible.”
D. “I exhale quickly through my mouth.”
Answer: B
Rationale: Pursed-lip breathing prolongs exhalation and prevents airway collapse,
improving ventilation in COPD.
5. A nurse is caring for a client receiving IV vancomycin. Which lab value is
most important to monitor?
A. WBC
B. Serum creatinine
C. ALT
D. Platelets
Answer: B
Rationale: Vancomycin is nephrotoxic; monitoring kidney function (serum creatinine) is
crucial to prevent renal damage.
,6. A client is post-op day 1 after abdominal surgery. Which assessment
finding requires immediate intervention?
A. Pain rated 7/10
B. Incision slightly reddened
C. No bowel sounds
D. Abdominal distention with absent bowel sounds and vomiting
Answer: D
Rationale: Abdominal distention with absent bowel sounds and vomiting may indicate
postoperative ileus or obstruction, which requires immediate attention.
7. Which action is appropriate when administering a subcutaneous
injection?
A. Insert the needle at 45–90°
B. Aspirate before injecting
C. Massage the site after injection
D. Use a 25-gauge, 2-inch needle
Answer: A
Rationale: Subcutaneous injections are typically given at 45°–90°, depending on the
amount of subcutaneous tissue. Aspirating is not recommended for most subcutaneous
injections.
8. A client is taking furosemide. Which statement indicates the client
understands the teaching?
A. “I will take it in the evening.”
B. “I may need to eat more potassium-rich foods.”
C. “I should avoid drinking fluids.”
D. “I do not need to monitor my weight.”
Answer: B
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. Clients should
include potassium-rich foods in their diet.
, 9. A nurse is preparing to insert a Foley catheter in a female client. Which is
the correct procedure?
A. Insert until urine flows, then advance 1–2 inches
B. Insert the catheter 5 inches before inflating the balloon
C. Inflate the balloon before urine appears
D. Use sterile gloves for cleaning, but clean gloves for insertion
Answer: A
Rationale: Once urine flows, advancing 1–2 inches ensures the balloon is fully inside the
bladder before inflation. Sterile technique is essential.
10. Which nursing diagnosis is appropriate for a client with chronic pain?
A. Risk for infection
B. Ineffective breathing pattern
C. Impaired physical mobility
D. Anxiety
Answer: C
Rationale: Chronic pain often limits mobility, making “Impaired physical mobility” the
most appropriate nursing diagnosis.
11. A client with hypertension is prescribed lisinopril. Which side effect
should the nurse teach the client to report immediately?
A. Dry cough
B. Fatigue
C. Swelling of lips and face
D. Dizziness
Answer: C
Rationale: Angioedema is a rare but life-threatening reaction to ACE inhibitors and
requires immediate attention.
12. The nurse is caring for a client with a nasogastric tube. Which action is
essential before administering enteral feeding?
Review for the NCLEX-RN® Examination,
9th Edition by Linda Anne Silvestri and
Angela Silvestri – Complete Questions
and Answers (Pass Guaranteed) ||
Updated 2025
1. A nurse is caring for a client with heart failure who has 3+ pitting edema.
Which nursing intervention is the highest priority?
A. Encourage ambulation
B. Elevate the legs
C. Administer diuretics as prescribed
D. Restrict fluid intake
Answer: C
Rationale: Diuretics help remove excess fluid and reduce edema, directly addressing the
underlying pathophysiology. Elevating legs is supportive but not the highest priority.
2. A client with diabetes mellitus has a blood glucose of 320 mg/dL and
fruity breath. Which complication is most likely?
A. Hypoglycemia
B. Diabetic ketoacidosis (DKA)
C. Hyperosmolar hyperglycemic state (HHS)
D. Insulin shock
Answer: B
Rationale: Hyperglycemia with fruity breath and polyuria suggests DKA, a complication
of uncontrolled type 1 diabetes.
,3. Which of the following is the most appropriate action for a nurse caring
for a client who suddenly develops shortness of breath and wheezing after
taking penicillin?
A. Document the reaction
B. Administer an antihistamine
C. Withhold the next dose
D. Call for emergency assistance
Answer: D
Rationale: Sudden wheezing after penicillin indicates a possible anaphylactic reaction,
which is life-threatening. Emergency intervention is required.
4. The nurse is teaching a client with COPD about pursed-lip breathing.
Which statement by the client indicates understanding?
A. “I inhale quickly through my mouth and exhale through my nose.”
B. “I exhale slowly through pursed lips.”
C. “I hold my breath as long as possible.”
D. “I exhale quickly through my mouth.”
Answer: B
Rationale: Pursed-lip breathing prolongs exhalation and prevents airway collapse,
improving ventilation in COPD.
5. A nurse is caring for a client receiving IV vancomycin. Which lab value is
most important to monitor?
A. WBC
B. Serum creatinine
C. ALT
D. Platelets
Answer: B
Rationale: Vancomycin is nephrotoxic; monitoring kidney function (serum creatinine) is
crucial to prevent renal damage.
,6. A client is post-op day 1 after abdominal surgery. Which assessment
finding requires immediate intervention?
A. Pain rated 7/10
B. Incision slightly reddened
C. No bowel sounds
D. Abdominal distention with absent bowel sounds and vomiting
Answer: D
Rationale: Abdominal distention with absent bowel sounds and vomiting may indicate
postoperative ileus or obstruction, which requires immediate attention.
7. Which action is appropriate when administering a subcutaneous
injection?
A. Insert the needle at 45–90°
B. Aspirate before injecting
C. Massage the site after injection
D. Use a 25-gauge, 2-inch needle
Answer: A
Rationale: Subcutaneous injections are typically given at 45°–90°, depending on the
amount of subcutaneous tissue. Aspirating is not recommended for most subcutaneous
injections.
8. A client is taking furosemide. Which statement indicates the client
understands the teaching?
A. “I will take it in the evening.”
B. “I may need to eat more potassium-rich foods.”
C. “I should avoid drinking fluids.”
D. “I do not need to monitor my weight.”
Answer: B
Rationale: Furosemide is a loop diuretic that can cause hypokalemia. Clients should
include potassium-rich foods in their diet.
, 9. A nurse is preparing to insert a Foley catheter in a female client. Which is
the correct procedure?
A. Insert until urine flows, then advance 1–2 inches
B. Insert the catheter 5 inches before inflating the balloon
C. Inflate the balloon before urine appears
D. Use sterile gloves for cleaning, but clean gloves for insertion
Answer: A
Rationale: Once urine flows, advancing 1–2 inches ensures the balloon is fully inside the
bladder before inflation. Sterile technique is essential.
10. Which nursing diagnosis is appropriate for a client with chronic pain?
A. Risk for infection
B. Ineffective breathing pattern
C. Impaired physical mobility
D. Anxiety
Answer: C
Rationale: Chronic pain often limits mobility, making “Impaired physical mobility” the
most appropriate nursing diagnosis.
11. A client with hypertension is prescribed lisinopril. Which side effect
should the nurse teach the client to report immediately?
A. Dry cough
B. Fatigue
C. Swelling of lips and face
D. Dizziness
Answer: C
Rationale: Angioedema is a rare but life-threatening reaction to ACE inhibitors and
requires immediate attention.
12. The nurse is caring for a client with a nasogastric tube. Which action is
essential before administering enteral feeding?
