Saunders NCLEX RN NGN Exam 2025 |
Complete Questions and Correct Answers
with Rationales | Graded A+ | Latest
Version | Just Released
After a tonsillectomy, a child is brought to the pediatric unit. The nurse should
appropriately place the child in which position?
1-Prone
2-Supine
3-High Fowler's
4-Trendelenburg ---------CORRECT ANSWER-----------------1-Prone
The child should be placed in a prone or side-lying position after tonsillectomy
to facilitate drainage. Options 2, 3, and 4 will not achieve this goal.
A nurse is monitoring a 7-year-old child who sustained a head injury in a motor
vehicle crash for signs of increased intracranial pressure (ICP). The nurse should
assess the child frequently for which early sign of increased ICP?
1-Nausea
2-Papilledema
3-Decerebrate posturing
,4-Alterations in pupil size ---------CORRECT ANSWER-----------------1-Nausea
Nausea is an early sign of increased ICP. Late signs of increased ICP include a
significant decrease in level of consciousness, Cushing's triad (increased systolic
blood pressure and widened pulse pressure, bradycardia, and irregular
respirations), and fixed and dilated pupils. Other late signs include decreased
motor response to command, decreased sensory response to painful stimuli,
posturing, Cheyne-Stokes respirations, and papilledema.
An older client says to the home care nurse, "I can't believe that my wife died
yesterday. I keep expecting to see her everywhere I go in this house, ready to plan
our activities for the day." Which is the therapeutic nursing response?
"It must be hard to accept that she has passed away."
"Are you saying that she made all the social plans for you?"
"Focus on the fact that her suffering is over and that she had a good life with
you."
"Try to focus on the fact that you have three wonderful children and that you and
your wife loved one another for years." ---------CORRECT ANSWER-----------------1-
"It must be hard to accept that she has passed away."
The therapeutic nursing response is the one that recognizes the difficulties of
grieving the loss of a loved one and facilitates expression of feelings. Options 2,
3, and 4 are not therapeutic because they do not encourage expression of
feelings.
,A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure.
Before administering the medication, the nurse double-checks the dose, counts
the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute.
Based on this finding, which is the appropriate nursing action?
1-Withhold the medication.
2-Administer the medication.
3-Double-check the apical heart rate and administer the medication.
4-Check the blood pressure and respirations and administer the medication. -------
--CORRECT ANSWER-----------------1-Withhold the medication.
Digoxin is a cardiac glycoside that is used to treat heart failure. A primary
concern is digoxin toxicity and the nurse needs to monitor closely for signs of
toxicity and monitor digoxin blood levels. The medication is effective within a
narrow therapeutic digoxin range (1.0 to 2.0 ng/mL). Safety in administration is
achieved by double-checking the dose and counting the apical heart rate for 1
full minute. If the heart rate is less than 100 beats/minute in an infant, the
nurse would withhold the dose and contact the health care provider. Therefore,
options 2, 3, and 4 are incorrect actions; it would be harmful to administer the
medication.
The nurse is performing an admission assessment on a client who has been
admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is
asking the client questions about pain. Which statement, if made by the client,
would support the diagnosis of gastric ulcer?
1-"The pain doesn't usually come right after I eat."
2-"The pain gets so bad that it wakes me up at night."
, 3-"The pain that I get is located on the right side of my chest."
4-"My pain comes shortly after I eat, maybe a half-hour or so later. ---------
CORRECT ANSWER-----------------4-"My pain comes shortly after I eat, maybe a
half-hour or so later.
Gastric ulcer pain often occurs in the upper epigastrium, with localization to the
left of the midline, and may be exacerbated by intake of food. The pain occurs
30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is
usually located to the right of the epigastrium. The pain associated with a
duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the
client at night.
The nurse is preparing to care for a client with immunodeficiency. The nurse
should plan to address which problem as the priority?
1-Anxiety
2-Fatigue
3-Risk for infection
4-Need for social isolation ---------CORRECT ANSWER-----------------3-Risk for
infection
The client with immunodeficiency has inadequate or no immune bodies and is
at risk for infection. The priority concern would be risk for infection. The
question presents no data indicating that the client is experiencing anxiety.
Fatigue may be a problem and the client may need to be placed on protective
isolation but these are not the priority problems for this client. Infection can be
life-threatening and is the priority.
Complete Questions and Correct Answers
with Rationales | Graded A+ | Latest
Version | Just Released
After a tonsillectomy, a child is brought to the pediatric unit. The nurse should
appropriately place the child in which position?
1-Prone
2-Supine
3-High Fowler's
4-Trendelenburg ---------CORRECT ANSWER-----------------1-Prone
The child should be placed in a prone or side-lying position after tonsillectomy
to facilitate drainage. Options 2, 3, and 4 will not achieve this goal.
A nurse is monitoring a 7-year-old child who sustained a head injury in a motor
vehicle crash for signs of increased intracranial pressure (ICP). The nurse should
assess the child frequently for which early sign of increased ICP?
1-Nausea
2-Papilledema
3-Decerebrate posturing
,4-Alterations in pupil size ---------CORRECT ANSWER-----------------1-Nausea
Nausea is an early sign of increased ICP. Late signs of increased ICP include a
significant decrease in level of consciousness, Cushing's triad (increased systolic
blood pressure and widened pulse pressure, bradycardia, and irregular
respirations), and fixed and dilated pupils. Other late signs include decreased
motor response to command, decreased sensory response to painful stimuli,
posturing, Cheyne-Stokes respirations, and papilledema.
An older client says to the home care nurse, "I can't believe that my wife died
yesterday. I keep expecting to see her everywhere I go in this house, ready to plan
our activities for the day." Which is the therapeutic nursing response?
"It must be hard to accept that she has passed away."
"Are you saying that she made all the social plans for you?"
"Focus on the fact that her suffering is over and that she had a good life with
you."
"Try to focus on the fact that you have three wonderful children and that you and
your wife loved one another for years." ---------CORRECT ANSWER-----------------1-
"It must be hard to accept that she has passed away."
The therapeutic nursing response is the one that recognizes the difficulties of
grieving the loss of a loved one and facilitates expression of feelings. Options 2,
3, and 4 are not therapeutic because they do not encourage expression of
feelings.
,A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure.
Before administering the medication, the nurse double-checks the dose, counts
the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute.
Based on this finding, which is the appropriate nursing action?
1-Withhold the medication.
2-Administer the medication.
3-Double-check the apical heart rate and administer the medication.
4-Check the blood pressure and respirations and administer the medication. -------
--CORRECT ANSWER-----------------1-Withhold the medication.
Digoxin is a cardiac glycoside that is used to treat heart failure. A primary
concern is digoxin toxicity and the nurse needs to monitor closely for signs of
toxicity and monitor digoxin blood levels. The medication is effective within a
narrow therapeutic digoxin range (1.0 to 2.0 ng/mL). Safety in administration is
achieved by double-checking the dose and counting the apical heart rate for 1
full minute. If the heart rate is less than 100 beats/minute in an infant, the
nurse would withhold the dose and contact the health care provider. Therefore,
options 2, 3, and 4 are incorrect actions; it would be harmful to administer the
medication.
The nurse is performing an admission assessment on a client who has been
admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is
asking the client questions about pain. Which statement, if made by the client,
would support the diagnosis of gastric ulcer?
1-"The pain doesn't usually come right after I eat."
2-"The pain gets so bad that it wakes me up at night."
, 3-"The pain that I get is located on the right side of my chest."
4-"My pain comes shortly after I eat, maybe a half-hour or so later. ---------
CORRECT ANSWER-----------------4-"My pain comes shortly after I eat, maybe a
half-hour or so later.
Gastric ulcer pain often occurs in the upper epigastrium, with localization to the
left of the midline, and may be exacerbated by intake of food. The pain occurs
30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is
usually located to the right of the epigastrium. The pain associated with a
duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the
client at night.
The nurse is preparing to care for a client with immunodeficiency. The nurse
should plan to address which problem as the priority?
1-Anxiety
2-Fatigue
3-Risk for infection
4-Need for social isolation ---------CORRECT ANSWER-----------------3-Risk for
infection
The client with immunodeficiency has inadequate or no immune bodies and is
at risk for infection. The priority concern would be risk for infection. The
question presents no data indicating that the client is experiencing anxiety.
Fatigue may be a problem and the client may need to be placed on protective
isolation but these are not the priority problems for this client. Infection can be
life-threatening and is the priority.
