Saunders NCLEX Questions With 100% Verified Answers
Graded A+
The nurse is assessing a client's postoperative normal.
pain using the PQRSTU method. Using this 4-Place the normal report in the client's medical
method, which questions would the nurse ask record. - ANSWERS - 1-Report the
the client? - ANSWERS - The PQRSTU abnormally low level.
method is one method of assessing pain. With
this method, the nurse asks about the following: The normal hematocrit level in a male ranges
Precipitating factors (option 6); Quality of the from 42% to 52%, and 35% to 47 % in a female,
pain (option 3); Region or Radiation of the pain depending on age. A hematocrit level of 30% is a
(option 1); Severity of the pain; Timing of the pain low level and would be reported to the health
(continuous or intermittent); and How the pain care provider because it indicates blood loss;
affects you (option 4). Options 2 and 5 may be therefore options 2, 3, and 4 are incorrect.
questions that would be asked; however, these
are not a part of the PQRSTU method.
A nurse provides dietary instructions to a client
who will be taking warfarin sodium (Coumadin).
The nurse is preparing to administer furosemide The nurse should tell the client to avoid which
(Lasix) to a client with a diagnosis of heart food item?
failure. Which is the most important laboratory
test result for the nurse to check before 1-Grapes
administering this medication? 2-Spinach
3-Watermelon
1-Blood urea nitrogen 4-Cottage cheese - ANSWERS - 2-Spinach
2-Cholesterol level
3-Potassium level Warfarin sodium is an anticoagulant.
4-Creatinine level - ANSWERS - Anticoagulant medications act by antagonizing
Furosemide is a loop diuretic. The medication the action of vitamin K, which is needed for
causes a decrease in the client's electrolytes, clotting. When a client is taking an anticoagulant,
especially potassium, sodium, and chloride. foods high in vitamin K often are omitted from the
Administering furosemide to a client with low diet. Vitamin K-rich foods include green leafy
electrolyte levels could precipitate ventricular vegetables, fish, liver, coffee, and tea.
dysrhythmias. Options 1 and 4 reflect renal
function. The cholesterol level is unrelated to the
administration of this medication.
A client who has been receiving total parenteral
nutrition (TPN) by way of a central venous
access device complains of chest pain and
A nurse caring for a client with a diagnosis of dyspnea. The nurse quickly assesses the client's
gastrointestinal (GI) bleeding reviews the client's vital signs and notes that the pulse rate has
laboratory results and notes a hematocrit level of increased and the blood pressure has dropped.
30%. Which action should the nurse take? The nurse determines that the client is most likely
experiencing which problem?
1-Report the abnormally low level.
2-Report the abnormally high level. 1-Sepsis
3-Inform the client that the laboratory result is 2-Air embolism
,Saunders NCLEX Questions With 100% Verified Answers
Graded A+
3-Fluid overload
4-Fluid imbalance - ANSWERS - 2-Air
embolism A nurse provides instructions to a preoperative
client about the use of an incentive spirometer.
The signs and symptoms of air embolism include The nurse determines that the client needs
chest pain, dyspnea, hypoxia, anxiety, further instruction if the client indicates that he or
tachycardia, and hypotension. The nurse also she will take which action?
may hear a loud churning sound over the
pericardium on auscultation of the client's chest. 1-Sit upright when using the device.
The signs and symptoms of sepsis include fever, 2-Inhale slowly, maintaining a constant flow.
chills, and general malaise. Fluid overload 3-Place the lips completely over the mouthpiece.
causes increased intravascular volume, which 4-After maximal inspiration, hold the breath for 10
increases the blood pressure and the pulse rate seconds and then exhale. - ANSWERS - 4-
as the heart tries to pump the extra fluid volume. After maximal inspiration, hold the breath for 10
Fluid overload also causes neck vein distention seconds and then exhale.
and shifting of fluid into the alveoli, resulting in
lung crackles. The signs and symptoms of a fluid For optimal lung expansion with the incentive
imbalance depend on the type of imbalance the spirometer, the client should assume a semi-
client is experiencing. 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
A client who is receiving intravenous (IV) fluid inspiration is reached, the client should hold the
therapy complains of burning and a feeling of breath for 2 or 3 seconds and then exhale slowly
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 The nurse is monitoring a client who has a closed
occurred? - ANSWERS - 1-Infection chest tube drainage system. The nurse notes
2-Phlebitis fluctuation of the fluid level in the water-seal
3-Infiltration chamber during inspiration and expiration. On the
4-Thrombosis basis of this finding, the nurse should make
which interpretation?
An infiltrated IV line is one that has dislodged
from the vein and is lying in subcutaneous tissue. 1-There is a leak in the system.
Pallor, coolness, and swelling at the IV site result 2-The chest tube is functioning as expected.
when IV fluid is deposited in the subcutaneous 3-The amount of suction needs to be decreased.
tissue. When the pressure in the tissues exceeds 4-The occlusive dressing at the insertion site
the pressure in the tubing, the flow of IV solution needs reinforcement. - ANSWERS - 2-The
will slow down or stop. The corrective action is to chest tube is functioning as expected.
remove the catheter and start a new IV line at
another site. The conditions identified in options The presence of fluctuation of the fluid level in
1, 2, and 4 are likely to be accompanied by the water-seal chamber indicates a patent
warmth at the site, not coolness. drainage system. With normal breathing, the
water level rises with inspiration and falls with
, Saunders NCLEX Questions With 100% Verified Answers
Graded A+
expiration. Fluctuation stops if the tube is and notes that the client is taking leflunomide
obstructed, if the suction is not working properly, (Arava). During assessment of the client, the
or if the lung has re-expanded. Options 1, 3, and nurse should ask which question to determine the
4 are incorrect interpretations of the finding. An effectiveness of this medication?
air leak may cause excessive bubbling in the
water seal chamber. Excessive and vigorous 1-"Do you have any joint pain?"
bubbling in the suction control chamber may 2-"Are you having any diarrhea?"
indicate that the amount of suction needs to be 3-"Are you experiencing heartburn?"
decreased. The status of the dressing is not 4-"Do you have frequent headaches?" -
specifically related to the presence of fluctuation ANSWERS - 1-"Do you have any joint
of the fluid level in the water-seal chamber pain?"
Leflunomide is an immunomodulatory agent and
has an anti-inflammatory action. The medication
A nurse is providing morning care to a client who provides symptomatic relief of rheumatoid
has a closed chest tube drainage system to treat arthritis. Diarrhea can occur as a side effect of
a pneumothorax. When the nurse turns the client the medication. Options 2, 3, and 4 are unrelated
to the side, the chest tube is accidentally to the action, use, or effectiveness of the
dislodged from the chest. The nurse immediately medication.
applies sterile gauze over the chest tube
insertion site. Which is the nurse's next action?
1-Call the health care provider. A nurse is checking lochia discharge in a woman
2-Replace the chest tube system. in the immediate postpartum period. The nurse
3-Obtain a pulse oximetry reading. notes that the lochia is bright red and contains
4-Place the client in a Trendelenburg position - some small clots. Based on this data, the nurse
ANSWERS - 1-Call the health care should make which interpretation?
provider.
1-The client is hemorrhaging.
2-The client needs to increase oral fluids.
If the chest drainage system is dislodged from 3-The client is experiencing normal lochia
the insertion site, the nurse immediately applies discharge.
sterile gauze over the site and calls the health 4-The client's health care provider needs to be
care provider. The nurse would maintain the notified of the finding. - ANSWERS - 3-The
client in an upright position. A new chest tube client is experiencing normal lochia discharge.
system may be attached if the tube requires
insertion, but this would not be the next action. Lochia, the uterine discharge present after birth,
Pulse oximetry readings would assist in initially is bright red and may contain small clots.
determining the client's respiratory status, but the
During the first 2 hours after birth, the amount of
priority action would be to call the health care uterine discharge should be approximately that of
provider in this emergency situation. a heavy menstrual period. After that time, the
lochial flow should steadily decrease, and the
color of the discharge should change to a pinkish
red or reddish brown. Because this is a normal,
A nurse reviews the medication history of a client expected occurrence, options 1, 2, and 4 are
Graded A+
The nurse is assessing a client's postoperative normal.
pain using the PQRSTU method. Using this 4-Place the normal report in the client's medical
method, which questions would the nurse ask record. - ANSWERS - 1-Report the
the client? - ANSWERS - The PQRSTU abnormally low level.
method is one method of assessing pain. With
this method, the nurse asks about the following: The normal hematocrit level in a male ranges
Precipitating factors (option 6); Quality of the from 42% to 52%, and 35% to 47 % in a female,
pain (option 3); Region or Radiation of the pain depending on age. A hematocrit level of 30% is a
(option 1); Severity of the pain; Timing of the pain low level and would be reported to the health
(continuous or intermittent); and How the pain care provider because it indicates blood loss;
affects you (option 4). Options 2 and 5 may be therefore options 2, 3, and 4 are incorrect.
questions that would be asked; however, these
are not a part of the PQRSTU method.
A nurse provides dietary instructions to a client
who will be taking warfarin sodium (Coumadin).
The nurse is preparing to administer furosemide The nurse should tell the client to avoid which
(Lasix) to a client with a diagnosis of heart food item?
failure. Which is the most important laboratory
test result for the nurse to check before 1-Grapes
administering this medication? 2-Spinach
3-Watermelon
1-Blood urea nitrogen 4-Cottage cheese - ANSWERS - 2-Spinach
2-Cholesterol level
3-Potassium level Warfarin sodium is an anticoagulant.
4-Creatinine level - ANSWERS - Anticoagulant medications act by antagonizing
Furosemide is a loop diuretic. The medication the action of vitamin K, which is needed for
causes a decrease in the client's electrolytes, clotting. When a client is taking an anticoagulant,
especially potassium, sodium, and chloride. foods high in vitamin K often are omitted from the
Administering furosemide to a client with low diet. Vitamin K-rich foods include green leafy
electrolyte levels could precipitate ventricular vegetables, fish, liver, coffee, and tea.
dysrhythmias. Options 1 and 4 reflect renal
function. The cholesterol level is unrelated to the
administration of this medication.
A client who has been receiving total parenteral
nutrition (TPN) by way of a central venous
access device complains of chest pain and
A nurse caring for a client with a diagnosis of dyspnea. The nurse quickly assesses the client's
gastrointestinal (GI) bleeding reviews the client's vital signs and notes that the pulse rate has
laboratory results and notes a hematocrit level of increased and the blood pressure has dropped.
30%. Which action should the nurse take? The nurse determines that the client is most likely
experiencing which problem?
1-Report the abnormally low level.
2-Report the abnormally high level. 1-Sepsis
3-Inform the client that the laboratory result is 2-Air embolism
,Saunders NCLEX Questions With 100% Verified Answers
Graded A+
3-Fluid overload
4-Fluid imbalance - ANSWERS - 2-Air
embolism A nurse provides instructions to a preoperative
client about the use of an incentive spirometer.
The signs and symptoms of air embolism include The nurse determines that the client needs
chest pain, dyspnea, hypoxia, anxiety, further instruction if the client indicates that he or
tachycardia, and hypotension. The nurse also she will take which action?
may hear a loud churning sound over the
pericardium on auscultation of the client's chest. 1-Sit upright when using the device.
The signs and symptoms of sepsis include fever, 2-Inhale slowly, maintaining a constant flow.
chills, and general malaise. Fluid overload 3-Place the lips completely over the mouthpiece.
causes increased intravascular volume, which 4-After maximal inspiration, hold the breath for 10
increases the blood pressure and the pulse rate seconds and then exhale. - ANSWERS - 4-
as the heart tries to pump the extra fluid volume. After maximal inspiration, hold the breath for 10
Fluid overload also causes neck vein distention seconds and then exhale.
and shifting of fluid into the alveoli, resulting in
lung crackles. The signs and symptoms of a fluid For optimal lung expansion with the incentive
imbalance depend on the type of imbalance the spirometer, the client should assume a semi-
client is experiencing. 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
A client who is receiving intravenous (IV) fluid inspiration is reached, the client should hold the
therapy complains of burning and a feeling of breath for 2 or 3 seconds and then exhale slowly
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 The nurse is monitoring a client who has a closed
occurred? - ANSWERS - 1-Infection chest tube drainage system. The nurse notes
2-Phlebitis fluctuation of the fluid level in the water-seal
3-Infiltration chamber during inspiration and expiration. On the
4-Thrombosis basis of this finding, the nurse should make
which interpretation?
An infiltrated IV line is one that has dislodged
from the vein and is lying in subcutaneous tissue. 1-There is a leak in the system.
Pallor, coolness, and swelling at the IV site result 2-The chest tube is functioning as expected.
when IV fluid is deposited in the subcutaneous 3-The amount of suction needs to be decreased.
tissue. When the pressure in the tissues exceeds 4-The occlusive dressing at the insertion site
the pressure in the tubing, the flow of IV solution needs reinforcement. - ANSWERS - 2-The
will slow down or stop. The corrective action is to chest tube is functioning as expected.
remove the catheter and start a new IV line at
another site. The conditions identified in options The presence of fluctuation of the fluid level in
1, 2, and 4 are likely to be accompanied by the water-seal chamber indicates a patent
warmth at the site, not coolness. drainage system. With normal breathing, the
water level rises with inspiration and falls with
, Saunders NCLEX Questions With 100% Verified Answers
Graded A+
expiration. Fluctuation stops if the tube is and notes that the client is taking leflunomide
obstructed, if the suction is not working properly, (Arava). During assessment of the client, the
or if the lung has re-expanded. Options 1, 3, and nurse should ask which question to determine the
4 are incorrect interpretations of the finding. An effectiveness of this medication?
air leak may cause excessive bubbling in the
water seal chamber. Excessive and vigorous 1-"Do you have any joint pain?"
bubbling in the suction control chamber may 2-"Are you having any diarrhea?"
indicate that the amount of suction needs to be 3-"Are you experiencing heartburn?"
decreased. The status of the dressing is not 4-"Do you have frequent headaches?" -
specifically related to the presence of fluctuation ANSWERS - 1-"Do you have any joint
of the fluid level in the water-seal chamber pain?"
Leflunomide is an immunomodulatory agent and
has an anti-inflammatory action. The medication
A nurse is providing morning care to a client who provides symptomatic relief of rheumatoid
has a closed chest tube drainage system to treat arthritis. Diarrhea can occur as a side effect of
a pneumothorax. When the nurse turns the client the medication. Options 2, 3, and 4 are unrelated
to the side, the chest tube is accidentally to the action, use, or effectiveness of the
dislodged from the chest. The nurse immediately medication.
applies sterile gauze over the chest tube
insertion site. Which is the nurse's next action?
1-Call the health care provider. A nurse is checking lochia discharge in a woman
2-Replace the chest tube system. in the immediate postpartum period. The nurse
3-Obtain a pulse oximetry reading. notes that the lochia is bright red and contains
4-Place the client in a Trendelenburg position - some small clots. Based on this data, the nurse
ANSWERS - 1-Call the health care should make which interpretation?
provider.
1-The client is hemorrhaging.
2-The client needs to increase oral fluids.
If the chest drainage system is dislodged from 3-The client is experiencing normal lochia
the insertion site, the nurse immediately applies discharge.
sterile gauze over the site and calls the health 4-The client's health care provider needs to be
care provider. The nurse would maintain the notified of the finding. - ANSWERS - 3-The
client in an upright position. A new chest tube client is experiencing normal lochia discharge.
system may be attached if the tube requires
insertion, but this would not be the next action. Lochia, the uterine discharge present after birth,
Pulse oximetry readings would assist in initially is bright red and may contain small clots.
determining the client's respiratory status, but the
During the first 2 hours after birth, the amount of
priority action would be to call the health care uterine discharge should be approximately that of
provider in this emergency situation. a heavy menstrual period. After that time, the
lochial flow should steadily decrease, and the
color of the discharge should change to a pinkish
red or reddish brown. Because this is a normal,
A nurse reviews the medication history of a client expected occurrence, options 1, 2, and 4 are
