Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
INTEGRATED REVIEW — COMPREHENSIVE NCLEX
PRACTICE PACK [FUNDAMENTALS,
PHARMACOLOGY, MEDICAL-SURGICAL,
MATERNITY, PEDIATRIC, EMERGENCY, AND
SPECIALTY SYSTEMS] TEST BANK
FUNDAMENTALS (15 items)
1 (SBA) — Application — SECE
A 72-year-old postoperative client with left hip arthroplasty is
being ambulated for the first time today. Which action by the
nurse takes priority?
A. Encourage the client to take three deep breaths before
standing.
B. Observe the client’s surgical incision dressing for drainage.
C. Assist the client to stand, providing a walker and guarding at
the hip.
,D. Ask the client about current pain level and offer PRN
analgesic.
Answer: C
Rationale:
• A: Deep breaths reduce atelectasis risk (good) but not
priority during first ambulation.
• B: Inspecting dressing is important but safety during
transfer is higher priority.
• C: Correct. Ensuring safe transfer with assistive device and
guarding prevents falls and dislocation — immediate safety
first (SECE).
• D: Pain control is important but the nurse can
simultaneously assess and assist; safety takes precedence.
2 (SBA) — Application — SECE
Which action best reduces cross-contamination when providing
wound care to two different clients?
A. Perform hand hygiene and change gloves between clients.
B. Wear the same mask and gown if they are both MRSA
negative.
C. Keep instruments on the bedside table and wipe them with
alcohol between uses.
D. Use sterile technique for both wounds without changing
gloves.
,Answer: A
Rationale:
• A: Correct. Hand hygiene and glove changes are standard
to prevent cross-contamination (SECE).
• B: Masks/gowns can be reused only per facility policy;
reuse risks contamination.
• C: Instruments require proper reprocessing; wiping with
alcohol is inadequate.
• D: Sterile technique must include changing gloves and
supplies between patients.
3 (SATA) — Application — HP/SECE
Select all instructions a nurse should include when teaching a
client how to use a home incentive spirometer:
A. Inhale slowly and deeply until the piston reaches the target.
B. Perform 10 slow, deep breaths every hour while awake.
C. Hold the breath for 3–5 seconds at maximum inspiration.
D. Use the device only when shortness of breath occurs.
E. Exhale normally after each breath and rest between efforts.
Answers: A, C, E
Rationale:
• A: Correct. Slow, deep inhalations improve lung expansion
(HP).
, • B: Frequency is higher (10 breaths every hour while awake
is low); typical recommendation is 10 times every hour —
but instruction should be "10–15 breaths every hour" —
option B wording too prescriptive; borderline — excluded
to match conservative teaching.
• C: Correct. Holding breath allows alveolar recruitment.
• D: Incentive spirometer is preventive, not only for dyspnea
— incorrect.
• E: Correct. Exhaling normally and resting prevents
hyperventilation.
4 (SBA) — Analysis — PSI
A client with newly diagnosed major depressive disorder tells
the nurse, "I feel hopeless and have been thinking life isn’t
worth living." Which nursing action is most appropriate?
A. Encourage the client to discuss feelings and ask about
suicidal plans.
B. Tell the client that feeling better will come with time.
C. Ask the client to promise not to harm self.
D. Provide brochures about community resources and crisis
lines.
Answer: A
Rationale:
PN® Examination
9th Edition
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
INTEGRATED REVIEW — COMPREHENSIVE NCLEX
PRACTICE PACK [FUNDAMENTALS,
PHARMACOLOGY, MEDICAL-SURGICAL,
MATERNITY, PEDIATRIC, EMERGENCY, AND
SPECIALTY SYSTEMS] TEST BANK
FUNDAMENTALS (15 items)
1 (SBA) — Application — SECE
A 72-year-old postoperative client with left hip arthroplasty is
being ambulated for the first time today. Which action by the
nurse takes priority?
A. Encourage the client to take three deep breaths before
standing.
B. Observe the client’s surgical incision dressing for drainage.
C. Assist the client to stand, providing a walker and guarding at
the hip.
,D. Ask the client about current pain level and offer PRN
analgesic.
Answer: C
Rationale:
• A: Deep breaths reduce atelectasis risk (good) but not
priority during first ambulation.
• B: Inspecting dressing is important but safety during
transfer is higher priority.
• C: Correct. Ensuring safe transfer with assistive device and
guarding prevents falls and dislocation — immediate safety
first (SECE).
• D: Pain control is important but the nurse can
simultaneously assess and assist; safety takes precedence.
2 (SBA) — Application — SECE
Which action best reduces cross-contamination when providing
wound care to two different clients?
A. Perform hand hygiene and change gloves between clients.
B. Wear the same mask and gown if they are both MRSA
negative.
C. Keep instruments on the bedside table and wipe them with
alcohol between uses.
D. Use sterile technique for both wounds without changing
gloves.
,Answer: A
Rationale:
• A: Correct. Hand hygiene and glove changes are standard
to prevent cross-contamination (SECE).
• B: Masks/gowns can be reused only per facility policy;
reuse risks contamination.
• C: Instruments require proper reprocessing; wiping with
alcohol is inadequate.
• D: Sterile technique must include changing gloves and
supplies between patients.
3 (SATA) — Application — HP/SECE
Select all instructions a nurse should include when teaching a
client how to use a home incentive spirometer:
A. Inhale slowly and deeply until the piston reaches the target.
B. Perform 10 slow, deep breaths every hour while awake.
C. Hold the breath for 3–5 seconds at maximum inspiration.
D. Use the device only when shortness of breath occurs.
E. Exhale normally after each breath and rest between efforts.
Answers: A, C, E
Rationale:
• A: Correct. Slow, deep inhalations improve lung expansion
(HP).
, • B: Frequency is higher (10 breaths every hour while awake
is low); typical recommendation is 10 times every hour —
but instruction should be "10–15 breaths every hour" —
option B wording too prescriptive; borderline — excluded
to match conservative teaching.
• C: Correct. Holding breath allows alveolar recruitment.
• D: Incentive spirometer is preventive, not only for dyspnea
— incorrect.
• E: Correct. Exhaling normally and resting prevents
hyperventilation.
4 (SBA) — Analysis — PSI
A client with newly diagnosed major depressive disorder tells
the nurse, "I feel hopeless and have been thinking life isn’t
worth living." Which nursing action is most appropriate?
A. Encourage the client to discuss feelings and ask about
suicidal plans.
B. Tell the client that feeling better will come with time.
C. Ask the client to promise not to harm self.
D. Provide brochures about community resources and crisis
lines.
Answer: A
Rationale:
