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SAUNDERS NCLEX RN NGN NEWEST 2025/2026 NEWEST
ACTUAL EXAM WITH COMPLETE QUESTIONS AND
VERIFIED ANSWERS |ALREADY GRADED A+|
A pregnant client asks the nurse in the clinic when she will be able
to start feeling the fetus move. The nurse responds by telling the
mother that fetal movements will be noted between which weeks
of gestation? - ANSWER-Quickening is fetal movement that
usually first occurs between 16 and 20 weeks' gestation. The
expectant mother first notices subtle fetal movements during this
time, and these gradually increase in intensity. Options 1, 2, and 3
are incorrect; these gestational time frames are too early for
quickening.
The nurse who works on the night shift enters the medication
room and finds a coworker with a tourniquet wrapped around the
upper arm. The coworker is about to insert a needle attached to a
syringe containing a clear liquid into the antecubital area. Which
action would be the appropriate initial action by the nurse? -
ANSWER-Nurse practice acts require reporting impaired nurses.
The board of nursing has jurisdiction over the practice of nursing
and may develop plans for treatment and supervision. This
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incident needs to be reported to the nursing supervisor, who will
then report to the board of nursing and other authorities as
required. Option 2 is not the appropriate action. Option 3 is not an
initial action. Security may be called if a disturbance occurs, but
no data in the question support this. Therefore, this is not the
appropriate initial action.
The nurse is reinforcing instructions to the mother of a preschool
child who was recently diagnosed with pediculosis capitis (head
lice). Which item should be included in discussions to prevent a
reinfestation? - ANSWER-The adult louse can survive up to 48
hours away from a host, although nits can hatch in 7 to 10 days if
they are shed into the environment. Thus, 2 weeks represents a
safe interval of time that prevents reinfestation from occurring. Hot
water and hot air should be used in the washer and dryer.
Shaving the hair is unnecessary with proper treatment and would
have an adverse psychological effect on the child. Insecticides
can endanger children and animals and should not be sprayed on
furniture and beds.
Which should be the anticipated therapeutic outcome of an
escharotomy procedure performed for a circumferential arm burn?
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- ANSWER-Escharotomies are performed to alleviate the
compartment syndrome that can occur when edema forms under
nondistensible eschar in a circumferential burn. Escharotomies
are performed through avascular eschar to subcutaneous fat.
Although bleeding may occur from the site, it is considered a
complication rather than an anticipated therapeutic outcome. The
formation of granulation tissue is not the intent of an escharotomy,
and escharotomy will not affect the formation of edema.
The nurse reinforces instructions to the client prescribed to take
cyclosporine oral solution. Which instruction should the nurse
primarily include? - ANSWER-To improve palatability, the client
should be taught to mix the concentrated medication solution with
chocolate milk or orange juice just before administration.
Grapefruit juice can raise cyclosporine levels. The client is
instructed to dispense the oral liquid into a glass container using a
specially calibrated pipette; mix it well and drink it immediately; fill
the container with a diluent such as water and drink it to ensure
ingestion of the complete dose; dry the outside of the pipette and
return to its cover for storage.
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A manic client is placed in a seclusion room after an outburst of
violent behavior, including physical assault on another client. As
the client is secluded, which action should the nurse perform? -
ANSWER-The client needs to be removed to a nonstimulating
environment because of the client's behavior. Options 2, 3, and 4
are nontherapeutic. Additionally, option 2 implies punishment. It is
best to directly inform the client of the purpose of the seclusion.
The nurse is preparing a discharge plan for a client who
attempted suicide. The nurse understands that the plan of care
should focus on which intervention? - ANSWER-The client's plan
of care needs to focus on contracts and immediate available crisis
resources. Crisis times may occur between appointments.
Contracts facilitate clients feeling responsibility for keeping a
promise, which gives the client control. Option 4 is unrealistic.
Providing phone numbers (option 2) will not ensure available and
immediate crisis intervention.
A 3-year-old child is hospitalized because of persistent vomiting.
Which conditions should the nurse expect this child to be high risk
for? Select all that apply. - ANSWER-Vomiting will cause the loss
of hydrochloric acid and subsequent metabolic alkalosis.
SAUNDERS NCLEX RN NGN NEWEST 2025/2026 NEWEST
ACTUAL EXAM WITH COMPLETE QUESTIONS AND
VERIFIED ANSWERS |ALREADY GRADED A+|
A pregnant client asks the nurse in the clinic when she will be able
to start feeling the fetus move. The nurse responds by telling the
mother that fetal movements will be noted between which weeks
of gestation? - ANSWER-Quickening is fetal movement that
usually first occurs between 16 and 20 weeks' gestation. The
expectant mother first notices subtle fetal movements during this
time, and these gradually increase in intensity. Options 1, 2, and 3
are incorrect; these gestational time frames are too early for
quickening.
The nurse who works on the night shift enters the medication
room and finds a coworker with a tourniquet wrapped around the
upper arm. The coworker is about to insert a needle attached to a
syringe containing a clear liquid into the antecubital area. Which
action would be the appropriate initial action by the nurse? -
ANSWER-Nurse practice acts require reporting impaired nurses.
The board of nursing has jurisdiction over the practice of nursing
and may develop plans for treatment and supervision. This
, Page |2
incident needs to be reported to the nursing supervisor, who will
then report to the board of nursing and other authorities as
required. Option 2 is not the appropriate action. Option 3 is not an
initial action. Security may be called if a disturbance occurs, but
no data in the question support this. Therefore, this is not the
appropriate initial action.
The nurse is reinforcing instructions to the mother of a preschool
child who was recently diagnosed with pediculosis capitis (head
lice). Which item should be included in discussions to prevent a
reinfestation? - ANSWER-The adult louse can survive up to 48
hours away from a host, although nits can hatch in 7 to 10 days if
they are shed into the environment. Thus, 2 weeks represents a
safe interval of time that prevents reinfestation from occurring. Hot
water and hot air should be used in the washer and dryer.
Shaving the hair is unnecessary with proper treatment and would
have an adverse psychological effect on the child. Insecticides
can endanger children and animals and should not be sprayed on
furniture and beds.
Which should be the anticipated therapeutic outcome of an
escharotomy procedure performed for a circumferential arm burn?
, Page |3
- ANSWER-Escharotomies are performed to alleviate the
compartment syndrome that can occur when edema forms under
nondistensible eschar in a circumferential burn. Escharotomies
are performed through avascular eschar to subcutaneous fat.
Although bleeding may occur from the site, it is considered a
complication rather than an anticipated therapeutic outcome. The
formation of granulation tissue is not the intent of an escharotomy,
and escharotomy will not affect the formation of edema.
The nurse reinforces instructions to the client prescribed to take
cyclosporine oral solution. Which instruction should the nurse
primarily include? - ANSWER-To improve palatability, the client
should be taught to mix the concentrated medication solution with
chocolate milk or orange juice just before administration.
Grapefruit juice can raise cyclosporine levels. The client is
instructed to dispense the oral liquid into a glass container using a
specially calibrated pipette; mix it well and drink it immediately; fill
the container with a diluent such as water and drink it to ensure
ingestion of the complete dose; dry the outside of the pipette and
return to its cover for storage.
, Page |4
A manic client is placed in a seclusion room after an outburst of
violent behavior, including physical assault on another client. As
the client is secluded, which action should the nurse perform? -
ANSWER-The client needs to be removed to a nonstimulating
environment because of the client's behavior. Options 2, 3, and 4
are nontherapeutic. Additionally, option 2 implies punishment. It is
best to directly inform the client of the purpose of the seclusion.
The nurse is preparing a discharge plan for a client who
attempted suicide. The nurse understands that the plan of care
should focus on which intervention? - ANSWER-The client's plan
of care needs to focus on contracts and immediate available crisis
resources. Crisis times may occur between appointments.
Contracts facilitate clients feeling responsibility for keeping a
promise, which gives the client control. Option 4 is unrealistic.
Providing phone numbers (option 2) will not ensure available and
immediate crisis intervention.
A 3-year-old child is hospitalized because of persistent vomiting.
Which conditions should the nurse expect this child to be high risk
for? Select all that apply. - ANSWER-Vomiting will cause the loss
of hydrochloric acid and subsequent metabolic alkalosis.
