Saunders NCLEX questions WITH
100% ACCURATE ANSWERS
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using
this method, which questions would the nurse ask the client? - correct answerThe
PQRSTU method is one method of assessing pain. With this method, the nurse asks
about the following: Precipitating factors (option 6); Quality of the pain (option 3);
Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain
(continuous or intermittent); and How the pain affects you (option 4). Options 2 and 5
may be questions that would be asked; however, these are not a part of the PQRSTU
method.
The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of
heart failure. Which is the most important laboratory test result for the nurse to check
before administering this medication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level - correct answerFurosemide is a loop diuretic. The medication causes
a decrease in the client's electrolytes, especially potassium, sodium, and chloride.
Administering furosemide to a client with low electrolyte levels could precipitate
ventricular dysrhythmias. Options 1 and 4 reflect renal function. The cholesterol level is
unrelated to the administration of this medication.
A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the
client's laboratory results and notes a hematocrit level of 30%. Which action should the
nurse take?
1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record. - correct answer1-Report the
abnormally low level.
The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a
female, depending on age. A hematocrit level of 30% is a low level and would be
reported to the health care provider because it indicates blood loss; therefore options 2,
3, and 4 are incorrect.
A nurse provides dietary instructions to a client who will be taking warfarin sodium
(Coumadin). The nurse should tell the client to avoid which food item?
,1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese - correct answer2-Spinach
Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the
action of vitamin K, which is needed for clotting. When a client is taking an
anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich
foods include green leafy vegetables, fish, liver, coffee, and tea.
A client who has been receiving total parenteral nutrition (TPN) by way of a central
venous access device complains of chest pain and dyspnea. The nurse quickly
assesses the client's vital signs and notes that the pulse rate has increased and the
blood pressure has dropped. The nurse determines that the client is most likely
experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - correct answer2-Air embolism
The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety,
tachycardia, and hypotension. The nurse also may hear a loud churning sound over the
pericardium on auscultation of the client's chest. The signs and symptoms of sepsis
include fever, chills, and general malaise. Fluid overload causes increased intravascular
volume, which increases the blood pressure and the pulse rate as the heart tries to
pump the extra fluid volume. Fluid overload also causes neck vein distention and
shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a
fluid imbalance depend on the type of imbalance the client is experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of burning and a
feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness
and swelling at the site and notes that the IV rate has slowed. The nurse determines
that which complication has occurred? - correct answer1-Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous
tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in
the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the
tubing, the flow of IV solution will slow down or stop. The corrective action is to remove
the catheter and start a new IV line at another site. The conditions identified in options
1, 2, and 4 are likely to be accompanied by warmth at the site, not coolness.
, A nurse provides instructions to a preoperative client about the use of an incentive
spirometer. The nurse determines that the client needs further instruction if the client
indicates that he or she will take which action?
1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale. - correct
answer4-After maximal inspiration, hold the breath for 10 seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client should assume a
semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely
and tightly while the client inhales slowly, with a constant flow through the unit. When
maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and
then exhale slowly
The nurse is monitoring a client who has a closed chest tube drainage system. The
nurse notes fluctuation of the fluid level in the water-seal chamber during inspiration and
expiration. On the basis of this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - correct answer2-
The chest tube is functioning as expected.
The presence of fluctuation of the fluid level in the water-seal chamber indicates a
patent drainage system. With normal breathing, the water level rises with inspiration and
falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not
working properly, or if the lung has re-expanded. Options 1, 3, and 4 are incorrect
interpretations of the finding. An air leak may cause excessive bubbling in the water
seal chamber. Excessive and vigorous bubbling in the suction control chamber may
indicate that the amount of suction needs to be decreased. The status of the dressing is
not specifically related to the presence of fluctuation of the fluid level in the water-seal
chamber
A nurse is providing morning care to a client who has a closed chest tube drainage
system to treat a pneumothorax. When the nurse turns the client to the side, the chest
tube is accidentally dislodged from the chest. The nurse immediately applies sterile
gauze over the chest tube insertion site. Which is the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - correct answer1-Call the health care
provider.
100% ACCURATE ANSWERS
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using
this method, which questions would the nurse ask the client? - correct answerThe
PQRSTU method is one method of assessing pain. With this method, the nurse asks
about the following: Precipitating factors (option 6); Quality of the pain (option 3);
Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain
(continuous or intermittent); and How the pain affects you (option 4). Options 2 and 5
may be questions that would be asked; however, these are not a part of the PQRSTU
method.
The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of
heart failure. Which is the most important laboratory test result for the nurse to check
before administering this medication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level - correct answerFurosemide is a loop diuretic. The medication causes
a decrease in the client's electrolytes, especially potassium, sodium, and chloride.
Administering furosemide to a client with low electrolyte levels could precipitate
ventricular dysrhythmias. Options 1 and 4 reflect renal function. The cholesterol level is
unrelated to the administration of this medication.
A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the
client's laboratory results and notes a hematocrit level of 30%. Which action should the
nurse take?
1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record. - correct answer1-Report the
abnormally low level.
The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a
female, depending on age. A hematocrit level of 30% is a low level and would be
reported to the health care provider because it indicates blood loss; therefore options 2,
3, and 4 are incorrect.
A nurse provides dietary instructions to a client who will be taking warfarin sodium
(Coumadin). The nurse should tell the client to avoid which food item?
,1-Grapes
2-Spinach
3-Watermelon
4-Cottage cheese - correct answer2-Spinach
Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the
action of vitamin K, which is needed for clotting. When a client is taking an
anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich
foods include green leafy vegetables, fish, liver, coffee, and tea.
A client who has been receiving total parenteral nutrition (TPN) by way of a central
venous access device complains of chest pain and dyspnea. The nurse quickly
assesses the client's vital signs and notes that the pulse rate has increased and the
blood pressure has dropped. The nurse determines that the client is most likely
experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - correct answer2-Air embolism
The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety,
tachycardia, and hypotension. The nurse also may hear a loud churning sound over the
pericardium on auscultation of the client's chest. The signs and symptoms of sepsis
include fever, chills, and general malaise. Fluid overload causes increased intravascular
volume, which increases the blood pressure and the pulse rate as the heart tries to
pump the extra fluid volume. Fluid overload also causes neck vein distention and
shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a
fluid imbalance depend on the type of imbalance the client is experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of burning and a
feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness
and swelling at the site and notes that the IV rate has slowed. The nurse determines
that which complication has occurred? - correct answer1-Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous
tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in
the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the
tubing, the flow of IV solution will slow down or stop. The corrective action is to remove
the catheter and start a new IV line at another site. The conditions identified in options
1, 2, and 4 are likely to be accompanied by warmth at the site, not coolness.
, A nurse provides instructions to a preoperative client about the use of an incentive
spirometer. The nurse determines that the client needs further instruction if the client
indicates that he or she will take which action?
1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale. - correct
answer4-After maximal inspiration, hold the breath for 10 seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client should assume a
semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely
and tightly while the client inhales slowly, with a constant flow through the unit. When
maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and
then exhale slowly
The nurse is monitoring a client who has a closed chest tube drainage system. The
nurse notes fluctuation of the fluid level in the water-seal chamber during inspiration and
expiration. On the basis of this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - correct answer2-
The chest tube is functioning as expected.
The presence of fluctuation of the fluid level in the water-seal chamber indicates a
patent drainage system. With normal breathing, the water level rises with inspiration and
falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not
working properly, or if the lung has re-expanded. Options 1, 3, and 4 are incorrect
interpretations of the finding. An air leak may cause excessive bubbling in the water
seal chamber. Excessive and vigorous bubbling in the suction control chamber may
indicate that the amount of suction needs to be decreased. The status of the dressing is
not specifically related to the presence of fluctuation of the fluid level in the water-seal
chamber
A nurse is providing morning care to a client who has a closed chest tube drainage
system to treat a pneumothorax. When the nurse turns the client to the side, the chest
tube is accidentally dislodged from the chest. The nurse immediately applies sterile
gauze over the chest tube insertion site. Which is the nurse's next action?
1-Call the health care provider.
2-Replace the chest tube system.
3-Obtain a pulse oximetry reading.
4-Place the client in a Trendelenburg position - correct answer1-Call the health care
provider.
