Saunders NCLEX questions
1. The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which
questions would the nurse ask the client?: The 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.
2. 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: Furosemide 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.
3. 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.: 1-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.
4. 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: 2-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.
5. 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
, Saunders NCLEX questions
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: 2-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.
6. 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?: 1-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.
7. 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.: 4-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
, Saunders NCLEX questions
8. 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.: 2-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-sea
chamber
9. 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: 1-Call the health care provider.
If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over
the site and calls the health care provider. The nurse would maintain the client in an upright position. A new chest
tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry
readings would assist in determining the client's respiratory status, but the priority action would be to call the
health care provider in this emergency situation. 10. A nurse reviews the medication history of a client and notes that
the client is taking leflunomide (Arava). During assessment of the client, the nurse should ask which question to
determine the effectiveness of this medication?
1-"Do you have any joint pain?"
2-"Are you having any diarrhea?"
3-"Are you experiencing heartburn?"
4-"Do you have frequent headaches?": 1-"Do you have any joint pain?"
1. The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which
questions would the nurse ask the client?: The 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.
2. 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: Furosemide 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.
3. 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.: 1-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.
4. 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: 2-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.
5. 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
, Saunders NCLEX questions
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: 2-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.
6. 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?: 1-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.
7. 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.: 4-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
, Saunders NCLEX questions
8. 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.: 2-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-sea
chamber
9. 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: 1-Call the health care provider.
If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over
the site and calls the health care provider. The nurse would maintain the client in an upright position. A new chest
tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry
readings would assist in determining the client's respiratory status, but the priority action would be to call the
health care provider in this emergency situation. 10. A nurse reviews the medication history of a client and notes that
the client is taking leflunomide (Arava). During assessment of the client, the nurse should ask which question to
determine the effectiveness of this medication?
1-"Do you have any joint pain?"
2-"Are you having any diarrhea?"
3-"Are you experiencing heartburn?"
4-"Do you have frequent headaches?": 1-"Do you have any joint pain?"
