SAUNDERS NCLEX EVALUATION EXAM 2025/2026
QUESTIONS WITH SOLUTIONS MARKED A+
✔✔The nurse is assessing the casted extremity of a client. Which sign is indicative of
infection?
1.
Dependent edema
2.
Diminished distal pulse
3.
Presence of a "hot spot" on the cast
4.
Coolness and pallor of the extremity - ✔✔Presence of a "hot spot" on the cast
Signs of infection under a casted area include odor or purulent drainage from the cast or
the presence of "hot spots," which are areas of the cast that are warmer than others.
The health care provider should be notified if any of these occur. Signs of impaired
circulation in the distal limb include coolness and pallor of the skin, diminished distal
pulse, and edema.
✔✔A client has sustained a closed fracture and has just had a cast applied to the
affected arm. The client is complaining of intense pain. The nurse elevates the limb,
applies an ice bag, and administers an analgesic, with little relief. Which problem may
be causing this pain?
1.
Infection under the cast
2.
The anxiety of the client
3.
Impaired tissue perfusion
4.
The recent occurrence of the fracture - ✔✔Impaired tissue perfusion
Most pain associated with fractures can be minimized with rest, elevation, application of
cold, and administration of analgesics. Pain that is not relieved by these measures
should be reported to the health care provider because pain unrelieved by medications
and other measures may indicate neurovascular compromise. Because this is a new
closed fracture and cast, infection would not have had time to set in. Intense pain after
casting is normally not associated with anxiety or the recent occurrence of the injury.
Treatment following the fracture should assist in relieving the pain associated with the
injury.
,✔✔The nurse is admitting a client with multiple trauma injuries to the nursing unit. The
client has a leg fracture and had a plaster cast applied. Which position would be best for
the casted leg?
1.
Elevated for 3 hours, then flat for 1 hour
2.
Flat for 3 hours, then elevated for 1 hour
3.
Flat for 12 hours, then elevated for 12 hours
4.
Elevated on pillows continuously for 24 to 48 hours - ✔✔Elevated on pillows
continuously for 24 to 48 hours
A casted extremity is elevated continuously for the first 24 to 48 hours to minimize
swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.
✔✔A client is being discharged to home after application of a plaster leg cast. Which
statement indicates that the client understands proper care of the cast?
1.
"I need to avoid getting the cast wet."
2.
"I need to cover the casted leg with warm blankets."
3.
"I need to use my fingertips to lift and move my leg."
4.
"I need to use something like a padded coat hanger end to scratch under the cast if it
itches." - ✔✔"I need to avoid getting the cast wet."
A plaster cast must remain dry to keep its strength. The cast should be handled with the
palms of the hands, not the fingertips, until fully dry; using the fingertips results in
indentations in the cast and skin pressure under the cast. Air should circulate freely
around the cast to help it dry; the cast also gives off heat as it dries. The client should
never scratch under the cast because of the risk of altered skin integrity; the client may
use a hair dryer on the cool setting to relieve an itch.
✔✔A client being measured for crutches asks the nurse why the crutches cannot rest
up underneath the arm for extra support. The nurse responds knowing that which would
most likely result from this improper crutch measurement?
1.
A fall and further injury
2.
,Injury to the brachial plexus nerves
3.
Skin breakdown in the area of the axilla
4.
Impaired range of motion while the client ambulates - ✔✔Injury to the brachial plexus
nerves
Crutches are measured so that the tops are 2 to 3 fingerwidths from the axillae. This
ensures that the client's axillae are not resting on the crutch or bearing the weight of the
crutch, which could result in injury to the nerves of the brachial plexus. Although the
conditions in options 1, 3, and 4 can occur, they are not the most likely result from
resting the axilla directly on the crutches.
✔✔The nurse has given the client instructions about crutch safety. Which statement
indicates that the client understands the instructions? Select all that apply.
1.
"I should not use someone else's crutches."
2.
"I need to remove any scatter rugs at home."
3.
"I can use crutch tips even when they are wet."
4.
"I need to have spare crutches and tips available."
5.
"When I'm using the crutches, my arms need to be completely straight." - ✔✔1.
"I should not use someone else's crutches."
2.
"I need to remove any scatter rugs at home."
4.
"I need to have spare crutches and tips available."
The client should use only crutches measured for the client. When assessing for home
safety, the nurse ensures that the client knows to remove any scatter rugs and does not
walk on highly waxed floors. The tips should be inspected for wear, and spare crutches
and tips should be available if needed. Crutch tips should remain dry. If crutch tips get
wet, the client should dry them with a cloth or paper towel. When walking with crutches,
both elbows need to be flexed not more than 30 degrees when the palms are on the
handle.
✔✔The nurse is caring for a client being treated for fat embolus after multiple fractures.
Which data would the nurse evaluate as the most favorable indication of resolution of
the fat embolus?
, 1.
Clear mentation
2.
Minimal dyspnea
3.
Oxygen saturation of 85%
4.
Arterial oxygen level of 78 mm Hg (10.3 kPa) - ✔✔Clear mentation
An altered mental state is an early indication of fat emboli; therefore, clear mentation is
a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a
normal sign. Arterial oxygen levels should be 80-100 mm Hg (10.6-13.33 kPa). Oxygen
saturation should be higher than 95%.
✔✔The nurse has conducted teaching with a client in an arm cast about the signs and
symptoms of compartment syndrome. The nurse determines that the client understands
the information if the client states that he or she should report which early symptom of
compartment syndrome?
1.
Cold, bluish-colored fingers
2.
Numbness and tingling in the fingers
3.
Pain that increases when the arm is dependent
4.
Pain that is out of proportion to the severity of the fracture - ✔✔Numbness and tingling
in the fingers
The earliest symptom of compartment syndrome is paresthesia (numbness and tingling
in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases
with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign.
Pain that is out of proportion to the severity of the fracture, along with other symptoms
associated with the pain, is not an early manifestation.
✔✔A client with diabetes mellitus has had a right below-knee amputation. Given the
client's history of diabetes mellitus, which complication is the client at most risk for after
surgery?
1.
Hemorrhage
2.
Edema of the residual limb
3.
QUESTIONS WITH SOLUTIONS MARKED A+
✔✔The nurse is assessing the casted extremity of a client. Which sign is indicative of
infection?
1.
Dependent edema
2.
Diminished distal pulse
3.
Presence of a "hot spot" on the cast
4.
Coolness and pallor of the extremity - ✔✔Presence of a "hot spot" on the cast
Signs of infection under a casted area include odor or purulent drainage from the cast or
the presence of "hot spots," which are areas of the cast that are warmer than others.
The health care provider should be notified if any of these occur. Signs of impaired
circulation in the distal limb include coolness and pallor of the skin, diminished distal
pulse, and edema.
✔✔A client has sustained a closed fracture and has just had a cast applied to the
affected arm. The client is complaining of intense pain. The nurse elevates the limb,
applies an ice bag, and administers an analgesic, with little relief. Which problem may
be causing this pain?
1.
Infection under the cast
2.
The anxiety of the client
3.
Impaired tissue perfusion
4.
The recent occurrence of the fracture - ✔✔Impaired tissue perfusion
Most pain associated with fractures can be minimized with rest, elevation, application of
cold, and administration of analgesics. Pain that is not relieved by these measures
should be reported to the health care provider because pain unrelieved by medications
and other measures may indicate neurovascular compromise. Because this is a new
closed fracture and cast, infection would not have had time to set in. Intense pain after
casting is normally not associated with anxiety or the recent occurrence of the injury.
Treatment following the fracture should assist in relieving the pain associated with the
injury.
,✔✔The nurse is admitting a client with multiple trauma injuries to the nursing unit. The
client has a leg fracture and had a plaster cast applied. Which position would be best for
the casted leg?
1.
Elevated for 3 hours, then flat for 1 hour
2.
Flat for 3 hours, then elevated for 1 hour
3.
Flat for 12 hours, then elevated for 12 hours
4.
Elevated on pillows continuously for 24 to 48 hours - ✔✔Elevated on pillows
continuously for 24 to 48 hours
A casted extremity is elevated continuously for the first 24 to 48 hours to minimize
swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.
✔✔A client is being discharged to home after application of a plaster leg cast. Which
statement indicates that the client understands proper care of the cast?
1.
"I need to avoid getting the cast wet."
2.
"I need to cover the casted leg with warm blankets."
3.
"I need to use my fingertips to lift and move my leg."
4.
"I need to use something like a padded coat hanger end to scratch under the cast if it
itches." - ✔✔"I need to avoid getting the cast wet."
A plaster cast must remain dry to keep its strength. The cast should be handled with the
palms of the hands, not the fingertips, until fully dry; using the fingertips results in
indentations in the cast and skin pressure under the cast. Air should circulate freely
around the cast to help it dry; the cast also gives off heat as it dries. The client should
never scratch under the cast because of the risk of altered skin integrity; the client may
use a hair dryer on the cool setting to relieve an itch.
✔✔A client being measured for crutches asks the nurse why the crutches cannot rest
up underneath the arm for extra support. The nurse responds knowing that which would
most likely result from this improper crutch measurement?
1.
A fall and further injury
2.
,Injury to the brachial plexus nerves
3.
Skin breakdown in the area of the axilla
4.
Impaired range of motion while the client ambulates - ✔✔Injury to the brachial plexus
nerves
Crutches are measured so that the tops are 2 to 3 fingerwidths from the axillae. This
ensures that the client's axillae are not resting on the crutch or bearing the weight of the
crutch, which could result in injury to the nerves of the brachial plexus. Although the
conditions in options 1, 3, and 4 can occur, they are not the most likely result from
resting the axilla directly on the crutches.
✔✔The nurse has given the client instructions about crutch safety. Which statement
indicates that the client understands the instructions? Select all that apply.
1.
"I should not use someone else's crutches."
2.
"I need to remove any scatter rugs at home."
3.
"I can use crutch tips even when they are wet."
4.
"I need to have spare crutches and tips available."
5.
"When I'm using the crutches, my arms need to be completely straight." - ✔✔1.
"I should not use someone else's crutches."
2.
"I need to remove any scatter rugs at home."
4.
"I need to have spare crutches and tips available."
The client should use only crutches measured for the client. When assessing for home
safety, the nurse ensures that the client knows to remove any scatter rugs and does not
walk on highly waxed floors. The tips should be inspected for wear, and spare crutches
and tips should be available if needed. Crutch tips should remain dry. If crutch tips get
wet, the client should dry them with a cloth or paper towel. When walking with crutches,
both elbows need to be flexed not more than 30 degrees when the palms are on the
handle.
✔✔The nurse is caring for a client being treated for fat embolus after multiple fractures.
Which data would the nurse evaluate as the most favorable indication of resolution of
the fat embolus?
, 1.
Clear mentation
2.
Minimal dyspnea
3.
Oxygen saturation of 85%
4.
Arterial oxygen level of 78 mm Hg (10.3 kPa) - ✔✔Clear mentation
An altered mental state is an early indication of fat emboli; therefore, clear mentation is
a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a
normal sign. Arterial oxygen levels should be 80-100 mm Hg (10.6-13.33 kPa). Oxygen
saturation should be higher than 95%.
✔✔The nurse has conducted teaching with a client in an arm cast about the signs and
symptoms of compartment syndrome. The nurse determines that the client understands
the information if the client states that he or she should report which early symptom of
compartment syndrome?
1.
Cold, bluish-colored fingers
2.
Numbness and tingling in the fingers
3.
Pain that increases when the arm is dependent
4.
Pain that is out of proportion to the severity of the fracture - ✔✔Numbness and tingling
in the fingers
The earliest symptom of compartment syndrome is paresthesia (numbness and tingling
in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases
with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign.
Pain that is out of proportion to the severity of the fracture, along with other symptoms
associated with the pain, is not an early manifestation.
✔✔A client with diabetes mellitus has had a right below-knee amputation. Given the
client's history of diabetes mellitus, which complication is the client at most risk for after
surgery?
1.
Hemorrhage
2.
Edema of the residual limb
3.
