Saunders Comprehensive NCLEX Review
Practice Questions
A 16-year-old client is admitted to the hospital for acute appendicitis and an
appendectomy is performed. Which intervention is the most appropriate to
facilitate normal growth and development post-operatively?
1. encourage the client to rest and read
2. encourage the parents to room in with the client
3. allow the family to bring in the client's favorite computer games
4. allow the client to interact with others in their same age group - ANS - 4. allow
the client to interact with others in their same age group
\a 2-year-old child is treated in the ED for a burn to the chest and abdomen. The
child sustained the burn by grabbing a cup of hot coffee on the kitchen counter.
The nurse reviews safety principles with the parents before discharge. Which
statement by the parents indicates an understanding of the teaching?
1. "we will be sure not to leave hot liquids unattended"
2. "I guess our kids need to understand what the word hot means"
3. "we will be sure the kids stay in their rooms while we work in the kitchen"
4. "we will install a safety gate so our kids cannot go into the kitchen" - ANS - 1.
"we will be sure not to leave hot liquids unattended"
\a 4 year old child diagnosed with leukemia is hospitalized for chemo. the child is
scared, which nursing intervention should be implemented to alleviate the child's
fears?
1. encourage the child's parents to stay with the child
2. encourage to play with other kids the same age
3. advise the family to only visit during scheduled visiting hours
4. provide a private room, allowing the child to bring their favorite toys from home
- ANS - 1. encourage the child's parents to stay with the child
\a 55 year old male client confides in the nurse that he is concerned about his
sexual function. what is the nurse's best response?
1. "how often do you have sexual relations"
2. "please share with me more about your concerns"
3. "you are still young and have nothing to be concerned about"
4. "you should not have a decline in testosterone until you are in your 80s" - ANS
- 2. "please share with me more about your concerns"
,\A child is receiving a series of HepB and arrives at the clinic with the parent for
the second dose. Before giving the vaccine, the nurse should ask the child and
parent about a history of severe allergy with which substance?
1. eggs
2. penicillin
3. sulfonamides
4. a previous dose of HepB vaccine or component - ANS - 4. a previous dose of
HepB vaccine or component
Rationale: the vaccine components of HepB are yeast protein and aluminum
hydroxide.
\a client arrives at a birthing center in active labor. after examination, it is
determined that her membranes are still intact and she is at -2 station. the PHCP
prepares to perform an amniotomy. what will the nurse relay to the client as the
most likely outcomes of the amniotomy? select all that apply
1. less pressure on her cervix
2. decreased # of contractions
3. increased efficacy of contractions
4. the need for increased maternal BP monitoring
5. the need for frequent FHR monitoring to detect the presence of a prolapsed
cord - ANS - 3, 5
Rationale: an amniotomy is artificial rupture of the membranes and is used to
induce labor when the cervix is favorable, or to augment labor if the progress is
slow. rupturing of the membranes allows the fetal head to contact the cervix more
directly and may increase the efficacy of contractions. increased monitoring of
maternal BP is unnecessary after this procedure. the FHR needs to be monitored
frequently, as there is an increased likelihood of a prolapsed cord with ruptured
membranes and a high presenting part.
\a client arrives at the clinic for the first prenatal assessment. she tells the nurse
that the first day of her last normal menstrual period was October 19th, 2020.
using Naegele's rule, which expected date of delivery should the nurse document
in the client's chart
1. July 12th, 2021
2. July 26th, 2021
3. August 12th, 2021
4. August 26th, 2021 - ANS - 2. July 26th, 2021
Rationale: add 7 days and 9 months to the date the last menstrual period ended.
,\A client brought to the ED states that he has accidentally been taking 2x his
prescribed dose of warfarin for the past week. After noting the client has no signs
of obvious bleeding, the nurse plans to take which action?
1. prepare to administer an antidote
2. draw a sample for type and crossmatch and transfuse the client
3. draw a sample for an aPTT level
4. draw a sample for a PT and international normalized ratio (INR) - ANS - 4. draw
a sample for a PT and international normalized ratio (INR)
Rationale: the action that the nurse should take is to draw a PT and INR level to
determine the client's anticoagulation status and risk for bleeding. These results
will provide info as to how to best treat this client. The aPTT measures the effects
of heparin therapy.
\A client diagnosed with conductive hearing loss asks the nurse to explain the
cause of the hearing problem. the nurse plans to explain to the client that this
condition is caused by which problem?
1. a deficit in the cochlea
2. a defect in the cranial nerve VIII
3. a physical obstruction to the transmission of sound waves
4. a defect in the sensory fibers that lead to the cerebral cortex - ANS - 3. a
physical obstruction to the transmission of sound waves
Rationale: a conductive hearing loss is the result of a physical obstruction to the
transmission of the sound waves.
\A client has been admitted to the hospital for gastroenteritis and dehydration.
The nurse determines that the client has received adequate volume replacement
if the blood urea nitrogen (BUN) level drops to which value?
1. 3 mg/dL (1.08 mmol/L)
2. 15 mg/dL (5.4 mmol/L)
3. 29 mg/dL (10.44 mmol/L)
4. 35 mg/dL (12.6 mmol/L) - ANS - 2. 15 mg/dL (5.4 mmol/L)
Rationale: the normal BUN level is 10-20 mg/dL (3.6 to 7.1 mmol/L). Values of 29
mg/dL (10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration.
A value of 3 mg/dL (1.08 mmol/L) reflects a lower than normal value, which may
occur with fluid overload.
\A client in labor is transported to the delivery room and prepared for a C-section.
After the client is transferred to the delivery room table, the nurse should place
the client in which position?
1. supine with a wedge under the right hip
, 2. Trendelenburg's with the legs in stirrups
3. prone with the legs separated and elevated
4. semi-fowler's with a pillow under the knees - ANS - 1. supine with a wedge
under the right hip
\a client in the 1st trimester arrives at a HC clinic and reports that she has been
experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse
instructs the client regarding management of care. which statement made by the
client indicates a need for further instruction?
1. "I will watch to see if I pass any tissue"
2. "I will maintain strict bed rest the remainder of my pregnancy"
3. "I will count the number of perineal pads used on a daily basis and note the
amount and color of blood on the pad"
4. "I will avoid intercourse until the bleeding has stopped and for 2 weeks
following the last episode of bleeding" - ANS - 2. "I will maintain strict bed rest
the remainder of my pregnancy"
\A client is brought to the ED by emergency medical services (EMS) after being
hit by a car. The name of the client is unknown, and the client has sustained a
severe head injury and multiple fractures and is unconscious. An emergency
craniotomy is required. Regarding informed consent for the surgical procedure,
which is the best action?
1. obtain a court order for the surgical procedure
2. ask the EMS team to sign the informed consent
3. transport the victim to the operating room for surgery
4. call the police to identify the client and notify the family - ANS - 3. transport the
victim to the operating room for surgery
Rationale: two situations where informed consent is not needed are when an
emergency is present and delaying treatment in order to get informed consent
would result in injury or death to the client, or when the client waives the right to
get informed consent.
\A client is receiving a continuous IV infusion of heparin sodium to treat deep
vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65
seconds. The nurse anticipates that which action is needed?
1. discontinuing the heparin infusion
2. increasing the rate of the heparin infusion
3. decreasing the rate of the heparin infusion
4. leaving the rate of the heparin infusion as it is - ANS - 4. leaving the rate of the
heparin infusion as it is
Practice Questions
A 16-year-old client is admitted to the hospital for acute appendicitis and an
appendectomy is performed. Which intervention is the most appropriate to
facilitate normal growth and development post-operatively?
1. encourage the client to rest and read
2. encourage the parents to room in with the client
3. allow the family to bring in the client's favorite computer games
4. allow the client to interact with others in their same age group - ANS - 4. allow
the client to interact with others in their same age group
\a 2-year-old child is treated in the ED for a burn to the chest and abdomen. The
child sustained the burn by grabbing a cup of hot coffee on the kitchen counter.
The nurse reviews safety principles with the parents before discharge. Which
statement by the parents indicates an understanding of the teaching?
1. "we will be sure not to leave hot liquids unattended"
2. "I guess our kids need to understand what the word hot means"
3. "we will be sure the kids stay in their rooms while we work in the kitchen"
4. "we will install a safety gate so our kids cannot go into the kitchen" - ANS - 1.
"we will be sure not to leave hot liquids unattended"
\a 4 year old child diagnosed with leukemia is hospitalized for chemo. the child is
scared, which nursing intervention should be implemented to alleviate the child's
fears?
1. encourage the child's parents to stay with the child
2. encourage to play with other kids the same age
3. advise the family to only visit during scheduled visiting hours
4. provide a private room, allowing the child to bring their favorite toys from home
- ANS - 1. encourage the child's parents to stay with the child
\a 55 year old male client confides in the nurse that he is concerned about his
sexual function. what is the nurse's best response?
1. "how often do you have sexual relations"
2. "please share with me more about your concerns"
3. "you are still young and have nothing to be concerned about"
4. "you should not have a decline in testosterone until you are in your 80s" - ANS
- 2. "please share with me more about your concerns"
,\A child is receiving a series of HepB and arrives at the clinic with the parent for
the second dose. Before giving the vaccine, the nurse should ask the child and
parent about a history of severe allergy with which substance?
1. eggs
2. penicillin
3. sulfonamides
4. a previous dose of HepB vaccine or component - ANS - 4. a previous dose of
HepB vaccine or component
Rationale: the vaccine components of HepB are yeast protein and aluminum
hydroxide.
\a client arrives at a birthing center in active labor. after examination, it is
determined that her membranes are still intact and she is at -2 station. the PHCP
prepares to perform an amniotomy. what will the nurse relay to the client as the
most likely outcomes of the amniotomy? select all that apply
1. less pressure on her cervix
2. decreased # of contractions
3. increased efficacy of contractions
4. the need for increased maternal BP monitoring
5. the need for frequent FHR monitoring to detect the presence of a prolapsed
cord - ANS - 3, 5
Rationale: an amniotomy is artificial rupture of the membranes and is used to
induce labor when the cervix is favorable, or to augment labor if the progress is
slow. rupturing of the membranes allows the fetal head to contact the cervix more
directly and may increase the efficacy of contractions. increased monitoring of
maternal BP is unnecessary after this procedure. the FHR needs to be monitored
frequently, as there is an increased likelihood of a prolapsed cord with ruptured
membranes and a high presenting part.
\a client arrives at the clinic for the first prenatal assessment. she tells the nurse
that the first day of her last normal menstrual period was October 19th, 2020.
using Naegele's rule, which expected date of delivery should the nurse document
in the client's chart
1. July 12th, 2021
2. July 26th, 2021
3. August 12th, 2021
4. August 26th, 2021 - ANS - 2. July 26th, 2021
Rationale: add 7 days and 9 months to the date the last menstrual period ended.
,\A client brought to the ED states that he has accidentally been taking 2x his
prescribed dose of warfarin for the past week. After noting the client has no signs
of obvious bleeding, the nurse plans to take which action?
1. prepare to administer an antidote
2. draw a sample for type and crossmatch and transfuse the client
3. draw a sample for an aPTT level
4. draw a sample for a PT and international normalized ratio (INR) - ANS - 4. draw
a sample for a PT and international normalized ratio (INR)
Rationale: the action that the nurse should take is to draw a PT and INR level to
determine the client's anticoagulation status and risk for bleeding. These results
will provide info as to how to best treat this client. The aPTT measures the effects
of heparin therapy.
\A client diagnosed with conductive hearing loss asks the nurse to explain the
cause of the hearing problem. the nurse plans to explain to the client that this
condition is caused by which problem?
1. a deficit in the cochlea
2. a defect in the cranial nerve VIII
3. a physical obstruction to the transmission of sound waves
4. a defect in the sensory fibers that lead to the cerebral cortex - ANS - 3. a
physical obstruction to the transmission of sound waves
Rationale: a conductive hearing loss is the result of a physical obstruction to the
transmission of the sound waves.
\A client has been admitted to the hospital for gastroenteritis and dehydration.
The nurse determines that the client has received adequate volume replacement
if the blood urea nitrogen (BUN) level drops to which value?
1. 3 mg/dL (1.08 mmol/L)
2. 15 mg/dL (5.4 mmol/L)
3. 29 mg/dL (10.44 mmol/L)
4. 35 mg/dL (12.6 mmol/L) - ANS - 2. 15 mg/dL (5.4 mmol/L)
Rationale: the normal BUN level is 10-20 mg/dL (3.6 to 7.1 mmol/L). Values of 29
mg/dL (10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration.
A value of 3 mg/dL (1.08 mmol/L) reflects a lower than normal value, which may
occur with fluid overload.
\A client in labor is transported to the delivery room and prepared for a C-section.
After the client is transferred to the delivery room table, the nurse should place
the client in which position?
1. supine with a wedge under the right hip
, 2. Trendelenburg's with the legs in stirrups
3. prone with the legs separated and elevated
4. semi-fowler's with a pillow under the knees - ANS - 1. supine with a wedge
under the right hip
\a client in the 1st trimester arrives at a HC clinic and reports that she has been
experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse
instructs the client regarding management of care. which statement made by the
client indicates a need for further instruction?
1. "I will watch to see if I pass any tissue"
2. "I will maintain strict bed rest the remainder of my pregnancy"
3. "I will count the number of perineal pads used on a daily basis and note the
amount and color of blood on the pad"
4. "I will avoid intercourse until the bleeding has stopped and for 2 weeks
following the last episode of bleeding" - ANS - 2. "I will maintain strict bed rest
the remainder of my pregnancy"
\A client is brought to the ED by emergency medical services (EMS) after being
hit by a car. The name of the client is unknown, and the client has sustained a
severe head injury and multiple fractures and is unconscious. An emergency
craniotomy is required. Regarding informed consent for the surgical procedure,
which is the best action?
1. obtain a court order for the surgical procedure
2. ask the EMS team to sign the informed consent
3. transport the victim to the operating room for surgery
4. call the police to identify the client and notify the family - ANS - 3. transport the
victim to the operating room for surgery
Rationale: two situations where informed consent is not needed are when an
emergency is present and delaying treatment in order to get informed consent
would result in injury or death to the client, or when the client waives the right to
get informed consent.
\A client is receiving a continuous IV infusion of heparin sodium to treat deep
vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65
seconds. The nurse anticipates that which action is needed?
1. discontinuing the heparin infusion
2. increasing the rate of the heparin infusion
3. decreasing the rate of the heparin infusion
4. leaving the rate of the heparin infusion as it is - ANS - 4. leaving the rate of the
heparin infusion as it is
