Page 1 of 85
“SAUNDERS ONLINE REVIEW FOR THE NCLEX-
RN EXAM 2026 ”LATEST EXAM 2026 – 2027
SOLVED QUESTIONS & ANSWERS VERIFIED
100% GRADED A+ (LATEST VERSION) WELL
REVISED 100% GUARANTEE PASS
day 6
don't miss any text contact me 254111429458
HESI/Saunders Online Review for the NCLEX-RN Examination
A client is receiving parenteral nutrition (PN) solution at 60 mL/hr by means of
infusion pump through a subclavian central line. The client calls the nurse and
complains of difficulty breathing and chest pain. The nurse notes that the
client's pulse rate is increased, the blood pressure has dropped, and oxygen
saturation is 89%. Use the number 1 to denote the first action and the number
4 the last.
~ Placing the client in lateral Trendelenburg position on the left side
~ Clamping the PN infusion catheter
~ Obtaining an electrocardiogram (ECG)
~ Notifying the physician
The correct order is:
1) Clamping the PN infusion catheter
2) Placing the client in lateral Trendelenburg position on the left side
3) Notifying the physician
4) Obtaining an electrocardiogram (ECG)Rationale: One complication of subclavian
, Page 2 of 85
central line insertion is embolism, air or thrombus. Signs and symptoms include
chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. On
auscultation, the nurse would hear a loud churning sound over the pericardium. If
this sign is detected, the PN infusion catheter is immediately clamped and the client
placed in a lateral Trendelenburg position on the left side, which helps trap the air in
the apex of the ventricle and prevents its ejection into the pulmonary arterial system.
The physician would be notified. An ECG may be obtained, but this would not be the
immediate action.
A nurse is preparing to administer digoxin (Lanoxin) to a client with heart
failure. On assessing of the client, the nurse notes an apical pulse rate of 58
beats/min and the client complains of anorexia and nausea. Which action
should the nurse take first on the basis of these assessment findings?
A) Contacting the physician
B) Administering an as-needed antiemetic
C) Checking the most recent digoxin level
D) Administering the digoxin with an antacid
Answer: C
Rationale: Anorexia and nausea are two of the symptoms most commonly
associated with digoxin toxicity. The nurse should withhold the digoxin until the
physician has been consulted if the pulse rate is slower than 60 beats/min, because
bradycardia is also an indication of digoxin toxicity. The nurse then checks the most
recent digoxin level, which will provide additional data to report to the physician — a
key follow-up nursing action. The nurse would not administer an antiemetic without
further investigating the client's problem.
A nurse is assessing a client who has undergone radical neck dissection for
the treatment of cancer. The nurse hears this sound when auscultating over
the trachea. On the basis of this finding, the priority nursing action is to:
A) Contact the physician
B) Assess the client's pulse oximetry
C) Place the client in a supine position
D) Administer a nebulizer treatment with the use of a bronchodilator
Answer: A
Rationale: The sound that the nurse hears is stridor. In the immediate postoperative
period, the nurse assesses the client for stridor, a high-pitched musical sound heard
, Page 3 of 85
on inspiration during auscultation over the trachea. This finding is reported
immediately because it indicates airway obstruction. The client is placed in the
Fowler position to facilitate breathing and promote comfort. Suctioning is performed
to remove secretions that cannot be expectorated by the client. Pulse oximetry may
be performed, but this is not the priority of the options provided. Administering a
nebulizer treatment with a bronchodilator is not indicated at this time.
A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes
mellitus who received NPH and regular humulin insulin at 7:30 am. At 11 am
the child suddenly complains of dizziness, headache, and a shaky feeling. The
nurse immediately:
A) Contacts the physician
B) Gives the child milk to drink
C) Arranges to have the child's lunch tray delivered early
D) Prepares to administer intravenous 5% dextrose solution
Answer: B
Rationale: Dizziness, headache, and a shaky feeling are signs of hypoglycemia. A
blood glucose reading will confirm the diagnosis and would be the initial action.
However, because this is not one of the options, the nurse would give the child milk
to drink because of the child's history and current symptoms indicating
hypoglycemia. Other items used to treat hypoglycemia include orange juice and hard
candy. The nurse would prepare to administer intravenous 5% dextrose solution if
the child were not responsive enough to safely take oral fluids, but this is not
indicated in the question. Arranging to have the child's lunch tray delivered early is
inappropriate because the child should eat meals at basically the same time each
day to achieve the best control of the diabetes. Contacting the physician would not
be the immediate action.
A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure
activity. The first action on the part of the nurse is:
A) Calling the physician
B) Inserting an oral airway
C) Turning the client on her side
D) Noting the time of the seizure
Answer: C
Rationale: If seizure activity occurs, the nurse remains with the client and presses
, Page 4 of 85
the emergency bell for assistance. The client is turned on her side because a side-
lying position permits greater circulation through the placenta and helps prevent
aspiration. The nurse then notes the time and sequence of the seizure. The
physician is notified that a seizure has occurred, because this is an obstetric
emergency associated with cerebral hemorrhage, abruptio placentae, severe fetal
hypoxia, and death. No object should be placed in the client's mouth during a
seizure. An airway may be inserted after the seizure, and the client's mouth and
nose are suctioned to prevent aspiration. Oxygen may be administered by way of
face mask during the seizure to increase oxygenation of the placenta and all
maternal organs.
A nurse performs a bedside glucose test on a newborn infant whose mother
has diabetes mellitus and obtains a reading of 35 mg/dL. The nurse would
first:
A) Ask the mother to breastfeed the newborn Incorrect
B) Bottle-feed the newborn with diluted glucose
C) Start an intravenous line for the administration of glucose
D) Ask the laboratory to perform a blood glucose test immediately
Answer: D
Rationale: The normal blood glucose level in a newborn is 40 mg/dL or higher.
Glucose levels of less than 40 to 45 mg/dL measured with bedside glucose
screening should be reported and verified in the laboratory. Although feeding is an
intervention, the result of a bedside glucose must be verified by the laboratory. Some
infants need IV glucose to maintain glucose balance and prevent damage to the
brain.
A pregnant woman is being admitted to the maternity unit. The woman tells the
nurse that she felt a large gush of fluid from her vagina on the way to the
hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical
examination, the nurse finds that the umbilical cord is protruding from the
vagina. Which of the following actions should the nurse perform? Select all
that apply.
A) Placing the woman in knee-chest position
B) Administering oxygen at 2 to 4 L/min by nasal cannula
C) Administering terbutaline (Brethine) to stop contractions
D) With two gloved fingers, exerting upward pressure, into the vagina, on the
“SAUNDERS ONLINE REVIEW FOR THE NCLEX-
RN EXAM 2026 ”LATEST EXAM 2026 – 2027
SOLVED QUESTIONS & ANSWERS VERIFIED
100% GRADED A+ (LATEST VERSION) WELL
REVISED 100% GUARANTEE PASS
day 6
don't miss any text contact me 254111429458
HESI/Saunders Online Review for the NCLEX-RN Examination
A client is receiving parenteral nutrition (PN) solution at 60 mL/hr by means of
infusion pump through a subclavian central line. The client calls the nurse and
complains of difficulty breathing and chest pain. The nurse notes that the
client's pulse rate is increased, the blood pressure has dropped, and oxygen
saturation is 89%. Use the number 1 to denote the first action and the number
4 the last.
~ Placing the client in lateral Trendelenburg position on the left side
~ Clamping the PN infusion catheter
~ Obtaining an electrocardiogram (ECG)
~ Notifying the physician
The correct order is:
1) Clamping the PN infusion catheter
2) Placing the client in lateral Trendelenburg position on the left side
3) Notifying the physician
4) Obtaining an electrocardiogram (ECG)Rationale: One complication of subclavian
, Page 2 of 85
central line insertion is embolism, air or thrombus. Signs and symptoms include
chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. On
auscultation, the nurse would hear a loud churning sound over the pericardium. If
this sign is detected, the PN infusion catheter is immediately clamped and the client
placed in a lateral Trendelenburg position on the left side, which helps trap the air in
the apex of the ventricle and prevents its ejection into the pulmonary arterial system.
The physician would be notified. An ECG may be obtained, but this would not be the
immediate action.
A nurse is preparing to administer digoxin (Lanoxin) to a client with heart
failure. On assessing of the client, the nurse notes an apical pulse rate of 58
beats/min and the client complains of anorexia and nausea. Which action
should the nurse take first on the basis of these assessment findings?
A) Contacting the physician
B) Administering an as-needed antiemetic
C) Checking the most recent digoxin level
D) Administering the digoxin with an antacid
Answer: C
Rationale: Anorexia and nausea are two of the symptoms most commonly
associated with digoxin toxicity. The nurse should withhold the digoxin until the
physician has been consulted if the pulse rate is slower than 60 beats/min, because
bradycardia is also an indication of digoxin toxicity. The nurse then checks the most
recent digoxin level, which will provide additional data to report to the physician — a
key follow-up nursing action. The nurse would not administer an antiemetic without
further investigating the client's problem.
A nurse is assessing a client who has undergone radical neck dissection for
the treatment of cancer. The nurse hears this sound when auscultating over
the trachea. On the basis of this finding, the priority nursing action is to:
A) Contact the physician
B) Assess the client's pulse oximetry
C) Place the client in a supine position
D) Administer a nebulizer treatment with the use of a bronchodilator
Answer: A
Rationale: The sound that the nurse hears is stridor. In the immediate postoperative
period, the nurse assesses the client for stridor, a high-pitched musical sound heard
, Page 3 of 85
on inspiration during auscultation over the trachea. This finding is reported
immediately because it indicates airway obstruction. The client is placed in the
Fowler position to facilitate breathing and promote comfort. Suctioning is performed
to remove secretions that cannot be expectorated by the client. Pulse oximetry may
be performed, but this is not the priority of the options provided. Administering a
nebulizer treatment with a bronchodilator is not indicated at this time.
A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes
mellitus who received NPH and regular humulin insulin at 7:30 am. At 11 am
the child suddenly complains of dizziness, headache, and a shaky feeling. The
nurse immediately:
A) Contacts the physician
B) Gives the child milk to drink
C) Arranges to have the child's lunch tray delivered early
D) Prepares to administer intravenous 5% dextrose solution
Answer: B
Rationale: Dizziness, headache, and a shaky feeling are signs of hypoglycemia. A
blood glucose reading will confirm the diagnosis and would be the initial action.
However, because this is not one of the options, the nurse would give the child milk
to drink because of the child's history and current symptoms indicating
hypoglycemia. Other items used to treat hypoglycemia include orange juice and hard
candy. The nurse would prepare to administer intravenous 5% dextrose solution if
the child were not responsive enough to safely take oral fluids, but this is not
indicated in the question. Arranging to have the child's lunch tray delivered early is
inappropriate because the child should eat meals at basically the same time each
day to achieve the best control of the diabetes. Contacting the physician would not
be the immediate action.
A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure
activity. The first action on the part of the nurse is:
A) Calling the physician
B) Inserting an oral airway
C) Turning the client on her side
D) Noting the time of the seizure
Answer: C
Rationale: If seizure activity occurs, the nurse remains with the client and presses
, Page 4 of 85
the emergency bell for assistance. The client is turned on her side because a side-
lying position permits greater circulation through the placenta and helps prevent
aspiration. The nurse then notes the time and sequence of the seizure. The
physician is notified that a seizure has occurred, because this is an obstetric
emergency associated with cerebral hemorrhage, abruptio placentae, severe fetal
hypoxia, and death. No object should be placed in the client's mouth during a
seizure. An airway may be inserted after the seizure, and the client's mouth and
nose are suctioned to prevent aspiration. Oxygen may be administered by way of
face mask during the seizure to increase oxygenation of the placenta and all
maternal organs.
A nurse performs a bedside glucose test on a newborn infant whose mother
has diabetes mellitus and obtains a reading of 35 mg/dL. The nurse would
first:
A) Ask the mother to breastfeed the newborn Incorrect
B) Bottle-feed the newborn with diluted glucose
C) Start an intravenous line for the administration of glucose
D) Ask the laboratory to perform a blood glucose test immediately
Answer: D
Rationale: The normal blood glucose level in a newborn is 40 mg/dL or higher.
Glucose levels of less than 40 to 45 mg/dL measured with bedside glucose
screening should be reported and verified in the laboratory. Although feeding is an
intervention, the result of a bedside glucose must be verified by the laboratory. Some
infants need IV glucose to maintain glucose balance and prevent damage to the
brain.
A pregnant woman is being admitted to the maternity unit. The woman tells the
nurse that she felt a large gush of fluid from her vagina on the way to the
hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical
examination, the nurse finds that the umbilical cord is protruding from the
vagina. Which of the following actions should the nurse perform? Select all
that apply.
A) Placing the woman in knee-chest position
B) Administering oxygen at 2 to 4 L/min by nasal cannula
C) Administering terbutaline (Brethine) to stop contractions
D) With two gloved fingers, exerting upward pressure, into the vagina, on the
