SAUNDERS NCLEX EXAM 2025
QUESTIONS AND 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? - ANS 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.
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
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,3-Potassium level
4-Creatinine level - ANS 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.
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. - ANS 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.
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,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 - ANS 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.
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?
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, 1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - ANS 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.
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? - ANS 1-Infection
2-Phlebitis
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QUESTIONS AND 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? - ANS 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.
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
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 1
,3-Potassium level
4-Creatinine level - ANS 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.
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. - ANS 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.
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,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 - ANS 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.
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?
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, 1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - ANS 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.
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? - ANS 1-Infection
2-Phlebitis
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