SAUNDERS NCLEX TEST PAPER 2025/2026 QUESTIONS
WITH SOLUTIONS MARKED A+
✔✔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?
1.
Sinus tachycardia
2.
Sinus bradycardia
3.
Sinus dysrhythmia
4.
Normal sinus rhythm - ✔✔Sinus tachycardia
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP
interval and normal-width PR and QRS intervals; however, the rate is the differentiating
factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100
beats/minute.
✔✔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?
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 neurovascular status is normal because of
increased blood flow through the leg.
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema
in the surgical extremity because of increased blood flow. The remaining options are
incorrect interpretations.
,✔✔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?
1.
Muffled heart sounds
2.
A rise in blood pressure
3.
Jugular venous distention
4.
Client expressions of dyspnea - ✔✔A rise in blood pressure
Following pericardiocentesis, the client usually expresses immediate relief. Heart
sounds are no longer muffled or distant and blood pressure increases. Distended neck
veins are a sign of increased venous pressure, which occurs with cardiac tamponade.
✔✔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?
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." - ✔✔"My spouse told me that since I have
developed this problem, we are going to stop walking in the mall every morning."
Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same
time each day, most often at rest. The pain is a result of coronary artery spasm. The
treatment of choice is usually a calcium channel blocker, which relaxes and dilates the
vascular smooth muscle, thus relieving the coronary artery spasm in variant angina.
Adverse effects can include peripheral edema, hypotension, bradycardia, and heart
failure. Grapefruit juice interacts with calcium channel blockers and should be avoided.
If bradycardia occurs, the client should contact the health care provider. Clients should
also be taught to change positions slowly to prevent orthostatic hypotension. Physical
exertion does not cause this type of angina; therefore, the client should be able to
continue morning walks with his or her spouse.
✔✔The nurse is monitoring a client with acute pericarditis for signs of cardiac
tamponade. Which assessment finding indicates the presence of this complication?
,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 - ✔✔Muffled or distant heart sounds
Assessment findings associated with cardiac tamponade include tachycardia, distant or
muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood
pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure
greater than 10 mm Hg). The other options are not signs of cardiac tamponade.
✔✔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?
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." - ✔✔"I need to be sure that I elevate my leg above the level of my heart for
at least an hour every day."
Foot care instructions for the client with peripheral arterial disease are the same as
those for a client with diabetes mellitus. The client with arterial disease, however, should
avoid raising the legs above the level of the heart unless instructed to do so as part of
an exercise program or if venous stasis is also present. The client statements in the
remaining options are correct statements, and indicate that the teaching has been
effective.
✔✔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?
1.
Bananas
2.
Broccoli
3.
, Antacids
4.
Cantaloupe - ✔✔Antacids
The sodium level can increase with the use of several types of products, including
toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids,
laxatives, and sedatives; and softened water and mineral water. Clients are instructed to
read labels for sodium content. Water that is bottled, distilled, deionized, or
demineralized may be used for drinking and cooking. Fresh fruits and vegetables are
low in sodium.
✔✔The nurse is preparing discharge instructions for a client with Raynaud's disease.
The nurse should plan to provide which instruction to the client?
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.
4.
Always wear warm clothing, even in warm climates, to prevent vasoconstriction. -
✔✔Stop smoking because it causes cutaneous blood vessel spasm.
Raynaud's disease is peripheral vascular disease characterized by abnormal
vasoconstriction in the extremities. Smoking cessation is one of the most important
lifestyle changes that the client must make. The nurse should emphasize the effects of
tobacco on the blood vessels and the principles involved in stopping smoking. The
nurse needs to provide information to the client about smoking cessation programs
available in the community. It is not necessary to wear gloves for all activities, nor
should warm clothing be worn in warm climates.
✔✔The nurse is developing a plan of care for a client with varicose veins in whom skin
breakdown occurred over the varicosities as a result of secondary infection. Which is a
priority intervention?
1.
Keep the legs aligned with the heart.
2.
Elevate the legs higher than the heart.
3.
Clean the skin with alcohol every hour.
4.
Position the client onto the side during every shift. - ✔✔Elevate the legs higher than the
heart.
WITH SOLUTIONS MARKED A+
✔✔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?
1.
Sinus tachycardia
2.
Sinus bradycardia
3.
Sinus dysrhythmia
4.
Normal sinus rhythm - ✔✔Sinus tachycardia
Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP
interval and normal-width PR and QRS intervals; however, the rate is the differentiating
factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100
beats/minute.
✔✔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?
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 neurovascular status is normal because of
increased blood flow through the leg.
An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema
in the surgical extremity because of increased blood flow. The remaining options are
incorrect interpretations.
,✔✔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?
1.
Muffled heart sounds
2.
A rise in blood pressure
3.
Jugular venous distention
4.
Client expressions of dyspnea - ✔✔A rise in blood pressure
Following pericardiocentesis, the client usually expresses immediate relief. Heart
sounds are no longer muffled or distant and blood pressure increases. Distended neck
veins are a sign of increased venous pressure, which occurs with cardiac tamponade.
✔✔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?
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." - ✔✔"My spouse told me that since I have
developed this problem, we are going to stop walking in the mall every morning."
Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same
time each day, most often at rest. The pain is a result of coronary artery spasm. The
treatment of choice is usually a calcium channel blocker, which relaxes and dilates the
vascular smooth muscle, thus relieving the coronary artery spasm in variant angina.
Adverse effects can include peripheral edema, hypotension, bradycardia, and heart
failure. Grapefruit juice interacts with calcium channel blockers and should be avoided.
If bradycardia occurs, the client should contact the health care provider. Clients should
also be taught to change positions slowly to prevent orthostatic hypotension. Physical
exertion does not cause this type of angina; therefore, the client should be able to
continue morning walks with his or her spouse.
✔✔The nurse is monitoring a client with acute pericarditis for signs of cardiac
tamponade. Which assessment finding indicates the presence of this complication?
,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 - ✔✔Muffled or distant heart sounds
Assessment findings associated with cardiac tamponade include tachycardia, distant or
muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood
pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure
greater than 10 mm Hg). The other options are not signs of cardiac tamponade.
✔✔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?
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." - ✔✔"I need to be sure that I elevate my leg above the level of my heart for
at least an hour every day."
Foot care instructions for the client with peripheral arterial disease are the same as
those for a client with diabetes mellitus. The client with arterial disease, however, should
avoid raising the legs above the level of the heart unless instructed to do so as part of
an exercise program or if venous stasis is also present. The client statements in the
remaining options are correct statements, and indicate that the teaching has been
effective.
✔✔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?
1.
Bananas
2.
Broccoli
3.
, Antacids
4.
Cantaloupe - ✔✔Antacids
The sodium level can increase with the use of several types of products, including
toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids,
laxatives, and sedatives; and softened water and mineral water. Clients are instructed to
read labels for sodium content. Water that is bottled, distilled, deionized, or
demineralized may be used for drinking and cooking. Fresh fruits and vegetables are
low in sodium.
✔✔The nurse is preparing discharge instructions for a client with Raynaud's disease.
The nurse should plan to provide which instruction to the client?
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.
4.
Always wear warm clothing, even in warm climates, to prevent vasoconstriction. -
✔✔Stop smoking because it causes cutaneous blood vessel spasm.
Raynaud's disease is peripheral vascular disease characterized by abnormal
vasoconstriction in the extremities. Smoking cessation is one of the most important
lifestyle changes that the client must make. The nurse should emphasize the effects of
tobacco on the blood vessels and the principles involved in stopping smoking. The
nurse needs to provide information to the client about smoking cessation programs
available in the community. It is not necessary to wear gloves for all activities, nor
should warm clothing be worn in warm climates.
✔✔The nurse is developing a plan of care for a client with varicose veins in whom skin
breakdown occurred over the varicosities as a result of secondary infection. Which is a
priority intervention?
1.
Keep the legs aligned with the heart.
2.
Elevate the legs higher than the heart.
3.
Clean the skin with alcohol every hour.
4.
Position the client onto the side during every shift. - ✔✔Elevate the legs higher than the
heart.
