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.
, Saunders NCLEX questions
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 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.
, Saunders NCLEX questions
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
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-seal
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
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.
, Saunders NCLEX questions
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 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.
, Saunders NCLEX questions
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
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-seal
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
