SAUNDERS NCLEX-RN® 9TH EDITION TEST BANK | 100+
VERIFIED QUESTIONS WITH RATIONALES | REAL EXAM
FORMAT | GRADE A+ PASS GUARANTEED
SECTION I: MANAGEMENT OF CARE (Questions 1–20)
Question 1
A nurse is caring for a client who has just been admitted with a diagnosis of active tuberculosis.
Which type of isolation precaution should the nurse implement?
A. Standard precautions only
B. Contact precautions
C. Airborne precautions
D. Droplet precautions
Correct Answer: C. Airborne precautions
Rationale: Tuberculosis is transmitted via airborne droplet nuclei that remain suspended in
the air for prolonged periods. Airborne precautions require a negative-pressure room, N95
respirator, and door kept closed. Contact precautions are for organisms spread by
direct/indirect contact (e.g., MRSA, C. difficile). Droplet precautions are for organisms spread by
large droplets (e.g., influenza, pertussis). Standard precautions apply to all clients but are
insufficient alone for TB.
Question 2
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is most
appropriate for the nurse to delegate?
A. Administering oral medications to a stable client
B. Assessing a newly admitted client's pain level
C. Obtaining vital signs on a stable postoperative client
D. Teaching a client how to perform self-catheterization
Correct Answer: C. Obtaining vital signs on a stable postoperative client
Rationale: Obtaining vital signs on a stable client is within the scope of UAP. Medication
administration, assessment, and client teaching are professional nursing responsibilities that
,cannot be delegated to UAP. The nurse must remember the five rights of delegation: right task,
right circumstance, right person, right direction/communication, and right supervision.
Question 3
A nurse is preparing to administer a blood transfusion. Which action should the nurse take first?
A. Verify the client's identity with another nurse
B. Obtain baseline vital signs
C. Prime the IV tubing with normal saline
D. Check the blood product expiration date
Correct Answer: B. Obtain baseline vital signs
Rationale: Baseline vital signs must be obtained before initiating a blood transfusion to
establish a comparison for detecting transfusion reactions. While all options are important,
baseline vitals are the first step in the transfusion protocol. The nurse should then verify the
blood product with another nurse, check expiration, and prime tubing with normal saline (never
lactated Ringer's).
Question 4
A nurse is serving as a preceptor for a new graduate. Which statement by the new graduate
indicates a need for further teaching regarding client confidentiality?
A. "I will discuss client information only in private areas."
B. "I can share client information with the client's family without consent."
C. "I will not post client information on social media."
D. "I will use the minimum necessary information when sharing with other providers."
Correct Answer: B. "I can share client information with the client's family without
consent."
Rationale: Client information cannot be shared with family members without the client's
consent, except in specific circumstances (e.g., emergency situations or when the client lacks
decision-making capacity). HIPAA regulations require protection of client privacy. All other
statements reflect correct understanding of confidentiality principles.
Question 5
,A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with chronic obstructive pulmonary disease (COPD) requesting pain medication
B. A client with a new onset of chest pain and shortness of breath
C. A client scheduled for discharge in 2 hours requesting discharge instructions
D. A client with diabetes requesting a snack
Correct Answer: B. A client with a new onset of chest pain and shortness of breath
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, the client with
new-onset chest pain and shortness of breath requires immediate assessment as this may
indicate myocardial infarction or pulmonary embolism. The other clients have less urgent needs.
The nurse should always prioritize clients with actual or potential life-threatening conditions.
Question 6
A nurse manager is reviewing incident reports. Which situation requires immediate follow-up by
the nurse manager?
A. A nurse forgot to document a client's meal intake
B. A nurse administered medication to the wrong client
C. A nurse arrived 10 minutes late for a shift
D. A nurse used the last glove in the box without restocking
Correct Answer: B. A nurse administered medication to the wrong client
Rationale: Medication errors are serious patient safety events that require immediate
follow-up, including assessment of the client, notification of the provider, and completion of an
incident report. While all situations may require attention, administering medication to the
wrong client is a critical safety event that could cause harm.
Question 7
A nurse is participating in a quality improvement committee. Which action best demonstrates
the nurse's understanding of quality improvement?
A. Reporting only errors that cause significant harm
B. Using data to identify trends and implement evidence-based changes
C. Waiting for administration to identify problems
D. Focusing only on individual performance rather than system issues
, Correct Answer: B. Using data to identify trends and implement evidence-based changes
Rationale: Quality improvement involves systematic data collection and analysis to identify
areas for improvement and implement evidence-based interventions. Nurses should report all
errors (near misses and actual), proactively identify problems, and recognize that most errors
result from system failures rather than individual incompetence.
Question 8
A nurse is caring for a client who speaks limited English. Which action should the nurse take to
ensure effective communication?
A. Ask the client's family member to interpret
B. Use a certified medical interpreter
C. Speak loudly and slowly in English
D. Provide written materials in English only
Correct Answer: B. Use a certified medical interpreter
Rationale: Federal law requires providing language assistance services to clients with
limited English proficiency. Using a certified medical interpreter ensures accurate
communication and protects client confidentiality. Family members should not be used as
interpreters due to potential for miscommunication, confidentiality breaches, and lack of
medical terminology knowledge.
Question 9
A nurse is making assignments for the day shift. Which client should be assigned to the most
experienced nurse?
A. A client with pneumonia receiving IV antibiotics
B. A client with a new tracheostomy requiring frequent suctioning
C. A client with a urinary tract infection on oral antibiotics
D. A client with a fractured arm in a cast
Correct Answer: B. A client with a new tracheostomy requiring frequent suctioning
Rationale: The client with a new tracheostomy requiring frequent suctioning has the highest
acuity and requires the most skilled nursing care due to potential airway complications. This
VERIFIED QUESTIONS WITH RATIONALES | REAL EXAM
FORMAT | GRADE A+ PASS GUARANTEED
SECTION I: MANAGEMENT OF CARE (Questions 1–20)
Question 1
A nurse is caring for a client who has just been admitted with a diagnosis of active tuberculosis.
Which type of isolation precaution should the nurse implement?
A. Standard precautions only
B. Contact precautions
C. Airborne precautions
D. Droplet precautions
Correct Answer: C. Airborne precautions
Rationale: Tuberculosis is transmitted via airborne droplet nuclei that remain suspended in
the air for prolonged periods. Airborne precautions require a negative-pressure room, N95
respirator, and door kept closed. Contact precautions are for organisms spread by
direct/indirect contact (e.g., MRSA, C. difficile). Droplet precautions are for organisms spread by
large droplets (e.g., influenza, pertussis). Standard precautions apply to all clients but are
insufficient alone for TB.
Question 2
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is most
appropriate for the nurse to delegate?
A. Administering oral medications to a stable client
B. Assessing a newly admitted client's pain level
C. Obtaining vital signs on a stable postoperative client
D. Teaching a client how to perform self-catheterization
Correct Answer: C. Obtaining vital signs on a stable postoperative client
Rationale: Obtaining vital signs on a stable client is within the scope of UAP. Medication
administration, assessment, and client teaching are professional nursing responsibilities that
,cannot be delegated to UAP. The nurse must remember the five rights of delegation: right task,
right circumstance, right person, right direction/communication, and right supervision.
Question 3
A nurse is preparing to administer a blood transfusion. Which action should the nurse take first?
A. Verify the client's identity with another nurse
B. Obtain baseline vital signs
C. Prime the IV tubing with normal saline
D. Check the blood product expiration date
Correct Answer: B. Obtain baseline vital signs
Rationale: Baseline vital signs must be obtained before initiating a blood transfusion to
establish a comparison for detecting transfusion reactions. While all options are important,
baseline vitals are the first step in the transfusion protocol. The nurse should then verify the
blood product with another nurse, check expiration, and prime tubing with normal saline (never
lactated Ringer's).
Question 4
A nurse is serving as a preceptor for a new graduate. Which statement by the new graduate
indicates a need for further teaching regarding client confidentiality?
A. "I will discuss client information only in private areas."
B. "I can share client information with the client's family without consent."
C. "I will not post client information on social media."
D. "I will use the minimum necessary information when sharing with other providers."
Correct Answer: B. "I can share client information with the client's family without
consent."
Rationale: Client information cannot be shared with family members without the client's
consent, except in specific circumstances (e.g., emergency situations or when the client lacks
decision-making capacity). HIPAA regulations require protection of client privacy. All other
statements reflect correct understanding of confidentiality principles.
Question 5
,A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with chronic obstructive pulmonary disease (COPD) requesting pain medication
B. A client with a new onset of chest pain and shortness of breath
C. A client scheduled for discharge in 2 hours requesting discharge instructions
D. A client with diabetes requesting a snack
Correct Answer: B. A client with a new onset of chest pain and shortness of breath
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework, the client with
new-onset chest pain and shortness of breath requires immediate assessment as this may
indicate myocardial infarction or pulmonary embolism. The other clients have less urgent needs.
The nurse should always prioritize clients with actual or potential life-threatening conditions.
Question 6
A nurse manager is reviewing incident reports. Which situation requires immediate follow-up by
the nurse manager?
A. A nurse forgot to document a client's meal intake
B. A nurse administered medication to the wrong client
C. A nurse arrived 10 minutes late for a shift
D. A nurse used the last glove in the box without restocking
Correct Answer: B. A nurse administered medication to the wrong client
Rationale: Medication errors are serious patient safety events that require immediate
follow-up, including assessment of the client, notification of the provider, and completion of an
incident report. While all situations may require attention, administering medication to the
wrong client is a critical safety event that could cause harm.
Question 7
A nurse is participating in a quality improvement committee. Which action best demonstrates
the nurse's understanding of quality improvement?
A. Reporting only errors that cause significant harm
B. Using data to identify trends and implement evidence-based changes
C. Waiting for administration to identify problems
D. Focusing only on individual performance rather than system issues
, Correct Answer: B. Using data to identify trends and implement evidence-based changes
Rationale: Quality improvement involves systematic data collection and analysis to identify
areas for improvement and implement evidence-based interventions. Nurses should report all
errors (near misses and actual), proactively identify problems, and recognize that most errors
result from system failures rather than individual incompetence.
Question 8
A nurse is caring for a client who speaks limited English. Which action should the nurse take to
ensure effective communication?
A. Ask the client's family member to interpret
B. Use a certified medical interpreter
C. Speak loudly and slowly in English
D. Provide written materials in English only
Correct Answer: B. Use a certified medical interpreter
Rationale: Federal law requires providing language assistance services to clients with
limited English proficiency. Using a certified medical interpreter ensures accurate
communication and protects client confidentiality. Family members should not be used as
interpreters due to potential for miscommunication, confidentiality breaches, and lack of
medical terminology knowledge.
Question 9
A nurse is making assignments for the day shift. Which client should be assigned to the most
experienced nurse?
A. A client with pneumonia receiving IV antibiotics
B. A client with a new tracheostomy requiring frequent suctioning
C. A client with a urinary tract infection on oral antibiotics
D. A client with a fractured arm in a cast
Correct Answer: B. A client with a new tracheostomy requiring frequent suctioning
Rationale: The client with a new tracheostomy requiring frequent suctioning has the highest
acuity and requires the most skilled nursing care due to potential airway complications. This
