SAUNDERS NCLEX COMPREHENSIVE
REVIEW STUDY QUESTIONS &
DETAILED CORRECT ANSWERS
ALREADY GRADED A+
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for
2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the
subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level
is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the
basis of these findings, the nurse would anticipate that the client is at risk for which problem? -
correct answer ✔✔1.Hypovolemia
2.Acute kidney injury*******
3.Glomerulonephritis
4.Urinary tract infection
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is
scheduled for cardiac catheterization. Which medication would need to be withheld for 24
hours before the procedure and for 48 hours after the procedure? - correct answer
✔✔1.Glipizide
2.Metformin*****
3.Repaglinide
4.Regular insulin
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are
regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall
heart rate is 64 beats/minute. Which action should the nurse take? - correct answer ✔✔1.Check
vital signs.
2.Check laboratory test results.
,3.Notify the health care provider.
4.Continue to monitor for any rhythm change.********
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse
sees no electrocardiographic complexes on the screen. Which is the priority nursing action? -
correct answer ✔✔1.Call a code.
2.Call the health care provider.
3.Check the client's status and lead placement.****** 4.Press the recorder button on the
electrocardiogram console.
The nurse is evaluating a client's response to cardioversion. Which assessment would be the
priority? - correct answer ✔✔1.Blood pressure
2.Status of airway*******
3.Oxygen flow rate
4.Level of consciousness
The nurse is caring for a client who has just had implantation of an automatic internal
cardioverter-defibrillator. The nurse should assess which item based on priority? - correct
answer ✔✔1. Anxiety level of the client and family
2.Presence of a MedicAlert card for the client to carry 3.Knowledge of restrictions on
postdischarge physical activity
4.Activation status of the device, heart rate cutoff, and number of shocks it is programmed to
deliver*******
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR
interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals
are regular. How should the nurse correctly interpret this rhythm? - correct answer ✔✔1.Sinus
tachycardia******
2.Sinus bradycardia
3.Sinus dysrhythmia
,4.Normal sinus rhythm
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing
unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the
nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission.
How should the nurse correctly interpret the client's neurovascular status? - correct answer
✔✔1. The neurovascular status is normal because of increased blood flow through the
leg.*******
2.The neurovascular status is moderately impaired, and the surgeon should be called.
3.The neurovascular status is slightly deteriorating and should be monitored for another hour.
4.The neurovascular status is adequate from an arterial approach, but venous complications are
arising.
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat
cardiac tamponade. Which observation would indicate that the procedure was effective? -
correct answer ✔✔1.
Muffled heart sounds
2.
A rise in blood pressure******
3.
Jugular venous distention
4.
Client expressions of dyspnea
A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily.
Which statement by the client indicates the need for further teaching? - correct answer ✔✔1."I
should notify my doctor if my feet or legs start to swell."
2."My doctor told me to call his office if my pulse rate decreases below 60."
3."Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every
morning with breakfast."
, 4."My spouse told me that since I have developed this problem, we are going to stop walking in
the mall every morning."*******
The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which
assessment finding indicates the presence of this complication? - correct answer ✔✔1.Flat neck
veins
2.A pulse rate of 60 beats/minute
3.Muffled or distant heart sounds****
4.Wheezing on auscultation of the lungs
The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer
about home care management and self-care management. Which statement, if made by the
client, indicates a need for further instruction? - correct answer ✔✔1."I need to be sure not to
go barefoot around the house."
2."If I cut my toenails, I need to be sure that I cut them straight across."
3."It is all right to apply lanolin to my feet, but I shouldn't place it between my toes."
4."I need to be sure that I elevate my leg above the level of my heart for at least an hour every
day."********
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-
sodium items to be avoided. The nurse instructs the client to avoid consuming which item? -
correct answer ✔✔1.Bananas
2.Broccoli
3.Antacids*******
4.Cantaloupe
The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse
should plan to provide which instruction to the client? - correct answer ✔✔1.Use nail polish to
protect the nail beds from injury. 2.Wear gloves for all activities involving the use of both hands.
3.Stop smoking because it causes cutaneous blood vessel spasm. ********
REVIEW STUDY QUESTIONS &
DETAILED CORRECT ANSWERS
ALREADY GRADED A+
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for
2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the
subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level
is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the
basis of these findings, the nurse would anticipate that the client is at risk for which problem? -
correct answer ✔✔1.Hypovolemia
2.Acute kidney injury*******
3.Glomerulonephritis
4.Urinary tract infection
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is
scheduled for cardiac catheterization. Which medication would need to be withheld for 24
hours before the procedure and for 48 hours after the procedure? - correct answer
✔✔1.Glipizide
2.Metformin*****
3.Repaglinide
4.Regular insulin
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are
regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall
heart rate is 64 beats/minute. Which action should the nurse take? - correct answer ✔✔1.Check
vital signs.
2.Check laboratory test results.
,3.Notify the health care provider.
4.Continue to monitor for any rhythm change.********
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse
sees no electrocardiographic complexes on the screen. Which is the priority nursing action? -
correct answer ✔✔1.Call a code.
2.Call the health care provider.
3.Check the client's status and lead placement.****** 4.Press the recorder button on the
electrocardiogram console.
The nurse is evaluating a client's response to cardioversion. Which assessment would be the
priority? - correct answer ✔✔1.Blood pressure
2.Status of airway*******
3.Oxygen flow rate
4.Level of consciousness
The nurse is caring for a client who has just had implantation of an automatic internal
cardioverter-defibrillator. The nurse should assess which item based on priority? - correct
answer ✔✔1. Anxiety level of the client and family
2.Presence of a MedicAlert card for the client to carry 3.Knowledge of restrictions on
postdischarge physical activity
4.Activation status of the device, heart rate cutoff, and number of shocks it is programmed to
deliver*******
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR
interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals
are regular. How should the nurse correctly interpret this rhythm? - correct answer ✔✔1.Sinus
tachycardia******
2.Sinus bradycardia
3.Sinus dysrhythmia
,4.Normal sinus rhythm
The nurse is assessing the neurovascular status of a client who returned to the surgical nursing
unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the
nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission.
How should the nurse correctly interpret the client's neurovascular status? - correct answer
✔✔1. The neurovascular status is normal because of increased blood flow through the
leg.*******
2.The neurovascular status is moderately impaired, and the surgeon should be called.
3.The neurovascular status is slightly deteriorating and should be monitored for another hour.
4.The neurovascular status is adequate from an arterial approach, but venous complications are
arising.
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat
cardiac tamponade. Which observation would indicate that the procedure was effective? -
correct answer ✔✔1.
Muffled heart sounds
2.
A rise in blood pressure******
3.
Jugular venous distention
4.
Client expressions of dyspnea
A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily.
Which statement by the client indicates the need for further teaching? - correct answer ✔✔1."I
should notify my doctor if my feet or legs start to swell."
2."My doctor told me to call his office if my pulse rate decreases below 60."
3."Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every
morning with breakfast."
, 4."My spouse told me that since I have developed this problem, we are going to stop walking in
the mall every morning."*******
The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which
assessment finding indicates the presence of this complication? - correct answer ✔✔1.Flat neck
veins
2.A pulse rate of 60 beats/minute
3.Muffled or distant heart sounds****
4.Wheezing on auscultation of the lungs
The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer
about home care management and self-care management. Which statement, if made by the
client, indicates a need for further instruction? - correct answer ✔✔1."I need to be sure not to
go barefoot around the house."
2."If I cut my toenails, I need to be sure that I cut them straight across."
3."It is all right to apply lanolin to my feet, but I shouldn't place it between my toes."
4."I need to be sure that I elevate my leg above the level of my heart for at least an hour every
day."********
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-
sodium items to be avoided. The nurse instructs the client to avoid consuming which item? -
correct answer ✔✔1.Bananas
2.Broccoli
3.Antacids*******
4.Cantaloupe
The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse
should plan to provide which instruction to the client? - correct answer ✔✔1.Use nail polish to
protect the nail beds from injury. 2.Wear gloves for all activities involving the use of both hands.
3.Stop smoking because it causes cutaneous blood vessel spasm. ********
