Saunders NCLEX questions
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this
method, which questions would the nurse ask the client? - ANSThe 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 - ANSFurosemide 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 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. - ANS1-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.
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 - ANS2-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?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - ANS2-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 complication has
occurred? - ANS1-Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue.
Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous
tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV
solution will slow down or stop. The corrective action is to remove the catheter and start a new
IV line at another site. The conditions identified in options 1, 2, and 4 are likely to be
accompanied by warmth at the site, not coolness.
A nurse provides instructions to a preoperative client about the use of an incentive spirometer.
The nurse determines that the client needs further instruction if the client indicates that he or
she will take which action?
1-Sit upright when using the device.
, 2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale. - ANS4-After
maximal inspiration, hold the breath for 10 seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client should assume a
semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and
tightly while the client inhales slowly, with a constant flow through the unit. When maximal
inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale
slowly
The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes
fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the
basis of this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - ANS2-The chest tube is
functioning as expected.
The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent
drainage system. With normal breathing, the water level rises with inspiration and falls with
expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if
the lung has re-expanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air
leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling
in the suction control chamber may indicate that the amount of suction needs to be decreased.
The status of the dressing is not specifically related to the presence of fluctuation of the fluid
level in the water-seal chamber
A nurse is providing morning care to a client who has a closed chest tube drainage system to
treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally
dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube
insertion site. Which is the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - ANS1-Call the health care provider.
If the chest drainage system is dislodged from the insertion site, the nurse immediately applies
sterile gauze over the site and calls the health care provider. The nurse would maintain the
client in an upright position. A new chest tube system may be attached if the tube requires
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this
method, which questions would the nurse ask the client? - ANSThe 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 - ANSFurosemide 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 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. - ANS1-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.
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 - ANS2-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?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - ANS2-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 complication has
occurred? - ANS1-Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue.
Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous
tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV
solution will slow down or stop. The corrective action is to remove the catheter and start a new
IV line at another site. The conditions identified in options 1, 2, and 4 are likely to be
accompanied by warmth at the site, not coolness.
A nurse provides instructions to a preoperative client about the use of an incentive spirometer.
The nurse determines that the client needs further instruction if the client indicates that he or
she will take which action?
1-Sit upright when using the device.
, 2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale. - ANS4-After
maximal inspiration, hold the breath for 10 seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client should assume a
semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and
tightly while the client inhales slowly, with a constant flow through the unit. When maximal
inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale
slowly
The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes
fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the
basis of this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - ANS2-The chest tube is
functioning as expected.
The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent
drainage system. With normal breathing, the water level rises with inspiration and falls with
expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if
the lung has re-expanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air
leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling
in the suction control chamber may indicate that the amount of suction needs to be decreased.
The status of the dressing is not specifically related to the presence of fluctuation of the fluid
level in the water-seal chamber
A nurse is providing morning care to a client who has a closed chest tube drainage system to
treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally
dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube
insertion site. Which is the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - ANS1-Call the health care provider.
If the chest drainage system is dislodged from the insertion site, the nurse immediately applies
sterile gauze over the site and calls the health care provider. The nurse would maintain the
client in an upright position. A new chest tube system may be attached if the tube requires
