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)
1. A nurse is preparing to administer a routine intramuscular
injection of 0.5 mL of influenza vaccine to an adult. Which
action best ensures the injection will be intramuscular
rather than subcutaneous?
A. Use a 25-gauge, ½-inch needle and inject at a 45° angle.
B. Use a 22-gauge, 1½-inch needle and inject at a 90°
angle. (Correct)
C. Use a 20-gauge, 1-inch needle and inject at a 30° angle.
, D. Use a 25-gauge, 5/8-inch needle and inject at a 90°
angle.
Answer: B.
Rationales:
A. 25-gauge ½-inch at 45° is appropriate for subcutaneous
injections, not reliably IM.
B. Correct. A 22-gauge, 1½-inch needle at 90° reaches the
muscle for an adult with average tissue.
C. 20-gauge, 1-inch at 30° is not deep enough/appropriate angle
for IM.
D. 25-gauge 5/8-inch at 90° may not reach muscle in adults with
normal adipose tissue.
2. A patient on a medical-surgical unit has sudden onset
confusion and a respiratory rate of 8 breaths/min. Which
nursing action has the highest priority?
A. Reorient the patient and provide a sitter.
B. Assess oxygen saturation and apply oxygen. (Correct)
C. Call the provider to report the confusion.
D. Obtain a full set of vital signs including blood pressure.
Answer: B.
Rationales:
A. Reorientation is appropriate for delirium but not the highest
priority when respiratory depression is present.
B. Correct. Low respiratory rate risks hypoxia; assessing
oxygenation and supporting airway/oxygen is immediate.
,(Airway/Breathing priority.)
C. Calling provider is important but after addressing immediate
oxygenation.
D. Vitals are important but oxygenation should be addressed
first.
3. A nurse is teaching a patient about infection prevention at
home after a Foley catheter removal. Which instruction is
most important to reduce UTI risk?
A. Drink at least 8–10 glasses of water daily. (Correct)
B. Use disposable feminine hygiene sprays if desired.
C. Take antibiotics for 3 days prophylactically.
D. Avoid all caffeine for one month.
Answer: A.
Rationales:
A. Correct. Adequate fluid intake promotes urinary flow and
reduces bacterial colonization.
B. Sprays are not recommended; they may irritate, but not the
most important preventive action.
C. Prophylactic antibiotics are not appropriate routinely due to
resistance.
D. Avoiding caffeine is not primary prevention for post-catheter
UTI.
, 4. The nurse identifies that a client’s central line dressing is
wet. The best next step is:
A. Reinforce dressing with extra tape and continue to
monitor.
B. Change the dressing using sterile technique as soon as
possible. (Correct)
C. Leave it; wet dressing indicates moisture and is
harmless.
D. Remove the central line immediately.
Answer: B.
Rationales:
A. Reinforcing a wet dressing fails to restore sterility.
B. Correct. Wet dressing compromises barrier; change promptly
using sterile technique.
C. Incorrect—moisture promotes microbial growth.
D. Immediate removal is not indicated unless infection or
malfunction is suspected.
5. A nurse teaches a patient with new diagnosis of
osteoporosis how to reduce fracture risk. Which statement
by the patient indicates correct understanding?
A. “I’ll do weight-bearing exercises like walking most days.”
(Correct)
B. “I do not need to worry about calcium if I take vitamin
D.”
C. “I will use a stool to reach high shelves to avoid
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)
1. A nurse is preparing to administer a routine intramuscular
injection of 0.5 mL of influenza vaccine to an adult. Which
action best ensures the injection will be intramuscular
rather than subcutaneous?
A. Use a 25-gauge, ½-inch needle and inject at a 45° angle.
B. Use a 22-gauge, 1½-inch needle and inject at a 90°
angle. (Correct)
C. Use a 20-gauge, 1-inch needle and inject at a 30° angle.
, D. Use a 25-gauge, 5/8-inch needle and inject at a 90°
angle.
Answer: B.
Rationales:
A. 25-gauge ½-inch at 45° is appropriate for subcutaneous
injections, not reliably IM.
B. Correct. A 22-gauge, 1½-inch needle at 90° reaches the
muscle for an adult with average tissue.
C. 20-gauge, 1-inch at 30° is not deep enough/appropriate angle
for IM.
D. 25-gauge 5/8-inch at 90° may not reach muscle in adults with
normal adipose tissue.
2. A patient on a medical-surgical unit has sudden onset
confusion and a respiratory rate of 8 breaths/min. Which
nursing action has the highest priority?
A. Reorient the patient and provide a sitter.
B. Assess oxygen saturation and apply oxygen. (Correct)
C. Call the provider to report the confusion.
D. Obtain a full set of vital signs including blood pressure.
Answer: B.
Rationales:
A. Reorientation is appropriate for delirium but not the highest
priority when respiratory depression is present.
B. Correct. Low respiratory rate risks hypoxia; assessing
oxygenation and supporting airway/oxygen is immediate.
,(Airway/Breathing priority.)
C. Calling provider is important but after addressing immediate
oxygenation.
D. Vitals are important but oxygenation should be addressed
first.
3. A nurse is teaching a patient about infection prevention at
home after a Foley catheter removal. Which instruction is
most important to reduce UTI risk?
A. Drink at least 8–10 glasses of water daily. (Correct)
B. Use disposable feminine hygiene sprays if desired.
C. Take antibiotics for 3 days prophylactically.
D. Avoid all caffeine for one month.
Answer: A.
Rationales:
A. Correct. Adequate fluid intake promotes urinary flow and
reduces bacterial colonization.
B. Sprays are not recommended; they may irritate, but not the
most important preventive action.
C. Prophylactic antibiotics are not appropriate routinely due to
resistance.
D. Avoiding caffeine is not primary prevention for post-catheter
UTI.
, 4. The nurse identifies that a client’s central line dressing is
wet. The best next step is:
A. Reinforce dressing with extra tape and continue to
monitor.
B. Change the dressing using sterile technique as soon as
possible. (Correct)
C. Leave it; wet dressing indicates moisture and is
harmless.
D. Remove the central line immediately.
Answer: B.
Rationales:
A. Reinforcing a wet dressing fails to restore sterility.
B. Correct. Wet dressing compromises barrier; change promptly
using sterile technique.
C. Incorrect—moisture promotes microbial growth.
D. Immediate removal is not indicated unless infection or
malfunction is suspected.
5. A nurse teaches a patient with new diagnosis of
osteoporosis how to reduce fracture risk. Which statement
by the patient indicates correct understanding?
A. “I’ll do weight-bearing exercises like walking most days.”
(Correct)
B. “I do not need to worry about calcium if I take vitamin
D.”
C. “I will use a stool to reach high shelves to avoid
