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
MEDICAL-SURGICAL (Q1–Q35) — 35 items
1 (Single-best-answer)
A client with chronic heart failure is prescribed spironolactone.
Which assessment finding requires immediate action?
A. 2+ pitting edema in ankles
B. Potassium 6.0 mEq/L
C. BP 110/70 mm Hg
D. Weight gain of 1 lb in 24 hours
,Answer: B. Potassium 6.0 mEq/L
Rationale:
• A: 2+ edema is common in HF and managed over time —
not immediate emergency. (Physiological Integrity —
Reduction of Risk Potential; Application)
• B: Hyperkalemia (≥6.0) is life-threatening and
spironolactone (K-sparing) increases K — immediate action
required (stop med, notify provider, cardiac monitoring).
(Safe & Effective Care Environment / Physiological
Integrity; Analysis)
• C: BP 110/70 is acceptable. (Physiological Integrity;
Application)
• D: 1 lb gain is mild and monitored; not immediate. (Health
Promotion/Physiological Integrity; Application)
2 (SATA)
A client with COPD is receiving supplemental oxygen via nasal
cannula at 2 L/min. Which nursing actions are appropriate?
(Select all that apply.)
A. Apply petroleum jelly to dry lips.
B. Encourage pursed-lip breathing.
C. Assess respiratory rate and effort hourly.
D. Increase O₂ flow to 6 L/min if dyspnea increases.
E. Ensure humidification is available if ordered.
,Answer: B, C, E
Rationale:
• A: Incorrect. Petroleum jelly is flammable — use water-
based products. (Safety & Infection Control; Application)
• B: Correct. Pursed-lip breathing improves ventilation and
reduces air trapping. (Physiological Integrity; Application)
• C: Correct. Frequent respiratory assessments are
appropriate for clients on O₂. (Safe & Effective Care
Environment; Application)
• D: Incorrect. Sudden increase to 6 L/min may be unsafe for
some COPD clients; follow provider orders and titrate
carefully with monitoring. (Physiological Integrity; Analysis)
• E: Correct. Humidification can relieve mucosal dryness at
low flows if ordered. (Fundamentals; Application)
3 (Single-best-answer)
A postop client develops sudden chest pain, shortness of
breath, and tachycardia on POD 2. Which action should the
nurse take first?
A. Administer subcutaneous heparin ordered PRN.
B. Auscultate lung fields and obtain pulse oximetry.
C. Encourage deep breathing and coughing.
D. Call the Rapid Response Team.
, Answer: B. Auscultate lung fields and obtain pulse oximetry.
Rationale:
• A: Heparin PRN without assessment is inappropriate. (Safe
& Effective Care Environment; Application)
• B: Correct. Immediate focused assessment (lung sounds,
SpO₂) identifies potential PE or other causes and guides
urgency. (Physiological Integrity; Analysis)
• C: Deep breathing may be harmful if embolism suspected;
assessment first. (Physiological Integrity; Application)
• D: Calling RRT may be appropriate after assessment if
unstable — but the nurse must assess immediately. (Safe &
Effective Care Environment; Evaluation)
4 (Matrix — Match drug side effect to mechanism)
Match each drug (rows) with the expected primary adverse
effect (columns). Choose the best match per row.
Rows:
1. ACE inhibitor (e.g., lisinopril)
2. Loop diuretic (e.g., furosemide)
3. Beta-blocker (e.g., metoprolol)
4. Aminoglycoside (e.g., gentamicin)
Columns: A. Hypokalemia, B. Cough, C. Bradycardia, D.
Ototoxicity
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
MEDICAL-SURGICAL (Q1–Q35) — 35 items
1 (Single-best-answer)
A client with chronic heart failure is prescribed spironolactone.
Which assessment finding requires immediate action?
A. 2+ pitting edema in ankles
B. Potassium 6.0 mEq/L
C. BP 110/70 mm Hg
D. Weight gain of 1 lb in 24 hours
,Answer: B. Potassium 6.0 mEq/L
Rationale:
• A: 2+ edema is common in HF and managed over time —
not immediate emergency. (Physiological Integrity —
Reduction of Risk Potential; Application)
• B: Hyperkalemia (≥6.0) is life-threatening and
spironolactone (K-sparing) increases K — immediate action
required (stop med, notify provider, cardiac monitoring).
(Safe & Effective Care Environment / Physiological
Integrity; Analysis)
• C: BP 110/70 is acceptable. (Physiological Integrity;
Application)
• D: 1 lb gain is mild and monitored; not immediate. (Health
Promotion/Physiological Integrity; Application)
2 (SATA)
A client with COPD is receiving supplemental oxygen via nasal
cannula at 2 L/min. Which nursing actions are appropriate?
(Select all that apply.)
A. Apply petroleum jelly to dry lips.
B. Encourage pursed-lip breathing.
C. Assess respiratory rate and effort hourly.
D. Increase O₂ flow to 6 L/min if dyspnea increases.
E. Ensure humidification is available if ordered.
,Answer: B, C, E
Rationale:
• A: Incorrect. Petroleum jelly is flammable — use water-
based products. (Safety & Infection Control; Application)
• B: Correct. Pursed-lip breathing improves ventilation and
reduces air trapping. (Physiological Integrity; Application)
• C: Correct. Frequent respiratory assessments are
appropriate for clients on O₂. (Safe & Effective Care
Environment; Application)
• D: Incorrect. Sudden increase to 6 L/min may be unsafe for
some COPD clients; follow provider orders and titrate
carefully with monitoring. (Physiological Integrity; Analysis)
• E: Correct. Humidification can relieve mucosal dryness at
low flows if ordered. (Fundamentals; Application)
3 (Single-best-answer)
A postop client develops sudden chest pain, shortness of
breath, and tachycardia on POD 2. Which action should the
nurse take first?
A. Administer subcutaneous heparin ordered PRN.
B. Auscultate lung fields and obtain pulse oximetry.
C. Encourage deep breathing and coughing.
D. Call the Rapid Response Team.
, Answer: B. Auscultate lung fields and obtain pulse oximetry.
Rationale:
• A: Heparin PRN without assessment is inappropriate. (Safe
& Effective Care Environment; Application)
• B: Correct. Immediate focused assessment (lung sounds,
SpO₂) identifies potential PE or other causes and guides
urgency. (Physiological Integrity; Analysis)
• C: Deep breathing may be harmful if embolism suspected;
assessment first. (Physiological Integrity; Application)
• D: Calling RRT may be appropriate after assessment if
unstable — but the nurse must assess immediately. (Safe &
Effective Care Environment; Evaluation)
4 (Matrix — Match drug side effect to mechanism)
Match each drug (rows) with the expected primary adverse
effect (columns). Choose the best match per row.
Rows:
1. ACE inhibitor (e.g., lisinopril)
2. Loop diuretic (e.g., furosemide)
3. Beta-blocker (e.g., metoprolol)
4. Aminoglycoside (e.g., gentamicin)
Columns: A. Hypokalemia, B. Cough, C. Bradycardia, D.
Ototoxicity
