Saunders NCLEX questions
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1. The nurse is assessing a The PQRSTU method is one method of assessing pain. With
client's postoperative pain us- this method, the nurse asks about the following: Precipitating
ing the PQRSTU method. Using factors (option 6); Quality of the pain (option 3); Region or
this method, which questions Radiation of the pain (option 1); Severity of the pain; Timing of
would the nurse ask the client? 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 ad- Furosemide is a loop diuretic. The medication causes a de-
minister furosemide (Lasix) to crease in the client's electrolytes, especially potassium, sodi-
a client with a diagnosis of um, and chloride. Administering furosemide to a client with
heart failure. Which is the most low electrolyte levels could precipitate ventricular dysrhyth-
important laboratory test re- mias. Options 1 and 4 reflect renal function. The cholesterol
sult for the nurse to check be- level is unrelated to the administration of this medication.
fore administering this med-
ication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level
3. A nurse caring for a client 1-Report the abnormally low level.
with a diagnosis of gastroin-
testinal (GI) bleeding reviews The normal hematocrit level in a male ranges from 42% to 52%,
the client's laboratory results and 35% to 47 % in a female, depending on age. A hematocrit
and notes a hematocrit level of level of 30% is a low level and would be reported to the health
30%. Which action should the care provider because it indicates blood loss; therefore options
nurse take? 2, 3, and 4 are incorrect.
1-Report the abnormally low
level.
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2-Report the abnormally high
level.
3-Inform the client that the lab-
oratory result is normal.
4-Place the normal report in
the client's medical record.
4. A nurse provides dietary in- 2-Spinach
structions to a client who
will be taking warfarin sodium Warfarin sodium is an anticoagulant. Anticoagulant medica-
(Coumadin). The nurse should tions act by antagonizing the action of vitamin K, which is
tell the client to avoid which needed for clotting. When a client is taking an anticoagulant,
food item? foods high in vitamin K often are omitted from the diet. Vitamin
K-rich foods include green leafy vegetables, fish, liver, coffee,
1-Grapes and tea.
2-Spinach
3-Watermelon
4-Cottage cheese
5. A client who has been receiv- 2-Air embolism
ing total parenteral nutrition
(TPN) by way of a central ve- The signs and symptoms of air embolism include chest pain,
nous access device complains dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The
of chest pain and dyspnea. nurse also may hear a loud churning sound over the peri-
The nurse quickly assesses the cardium on auscultation of the client's chest. The signs and
client's vital signs and notes symptoms of sepsis include fever, chills, and general malaise.
that the pulse rate has in- Fluid overload causes increased intravascular volume, which
creased and the blood pres- increases the blood pressure and the pulse rate as the heart
sure has dropped. The nurse tries to pump the extra fluid volume. Fluid overload also caus-
determines that the client is es neck vein distention and shifting of fluid into the alveoli,
most likely experiencing which resulting in lung crackles. The signs and symptoms of a fluid
problem?
, Saunders NCLEX questions
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imbalance depend on the type of imbalance the client is ex-
1-Sepsis periencing.
2-Air embolism
3-Fluid overload
4-Fluid imbalance
6. A client who is receiving intra- 1-Infection
venous (IV) fluid therapy com- 2-Phlebitis
plains of burning and a feeling 3-Infiltration
of tightness at the IV insertion 4-Thrombosis
site. On assessment, the nurse
detects coolness and swelling An infiltrated IV line is one that has dislodged from the vein and
at the site and notes that the is lying in subcutaneous tissue. Pallor, coolness, and swelling at
IV rate has slowed. The nurse the IV site result when IV fluid is deposited in the subcutaneous
determines that which compli- tissue. When the pressure in the tissues exceeds the pressure
cation has occurred? 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 4-After maximal inspiration, hold the breath for 10 seconds
to a preoperative client about and then exhale.
the use of an incentive spirom-
eter. The nurse determines For optimal lung expansion with the incentive spirometer, the
that the client needs further in- client should assume a semi-Fowler's or high Fowler's posi-
struction if the client indicates tion. The mouthpiece should be covered completely and tightly
that he or she will take which while the client inhales slowly, with a constant flow through the
action? unit. When maximal inspiration is reached, the client should
hold the breath for 2 or 3 seconds and then exhale slowly
1-Sit upright when using the
device.
2-Inhale slowly, maintaining a
, Saunders NCLEX questions
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constant flow.
3-Place the lips completely
over the mouthpiece.
4-After maximal inspiration,
hold the breath for 10 seconds
and then exhale.
8. The nurse is monitoring a 2-The chest tube is functioning as expected.
client who has a closed chest
tube drainage system. The The presence of fluctuation of the fluid level in the water-seal
nurse notes fluctuation of the chamber indicates a patent drainage system. With normal
fluid level in the water-seal breathing, the water level rises with inspiration and falls with
chamber during inspiration expiration. Fluctuation stops if the tube is obstructed, if the
and expiration. On the basis of suction is not working properly, or if the lung has re-expanded.
this finding, the nurse should Options 1, 3, and 4 are incorrect interpretations of the finding.
make which interpretation? An air leak may cause excessive bubbling in the water seal
chamber. Excessive and vigorous bubbling in the suction con-
1-There is a leak in the system. trol chamber may indicate that the amount of suction needs
2-The chest tube is functioning to be decreased. The status of the dressing is not specifically
as expected. related to the presence of fluctuation of the fluid level in the
3-The amount of suction needs water-seal chamber
to be decreased.
4-The occlusive dressing at the
insertion site needs reinforce-
ment.
9. A nurse is providing morn- 1-Call the health care provider.
ing care to a client who has
a closed chest tube drainage
If the chest drainage system is dislodged from the insertion
system to treat a pneumotho-
site, the nurse immediately applies sterile gauze over the site
rax. When the nurse turns the
and calls the health care provider. The nurse would maintain
client to the side, the chest
the client in an upright position. A new chest tube system may
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1. The nurse is assessing a The PQRSTU method is one method of assessing pain. With
client's postoperative pain us- this method, the nurse asks about the following: Precipitating
ing the PQRSTU method. Using factors (option 6); Quality of the pain (option 3); Region or
this method, which questions Radiation of the pain (option 1); Severity of the pain; Timing of
would the nurse ask the client? 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 ad- Furosemide is a loop diuretic. The medication causes a de-
minister furosemide (Lasix) to crease in the client's electrolytes, especially potassium, sodi-
a client with a diagnosis of um, and chloride. Administering furosemide to a client with
heart failure. Which is the most low electrolyte levels could precipitate ventricular dysrhyth-
important laboratory test re- mias. Options 1 and 4 reflect renal function. The cholesterol
sult for the nurse to check be- level is unrelated to the administration of this medication.
fore administering this med-
ication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level
3. A nurse caring for a client 1-Report the abnormally low level.
with a diagnosis of gastroin-
testinal (GI) bleeding reviews The normal hematocrit level in a male ranges from 42% to 52%,
the client's laboratory results and 35% to 47 % in a female, depending on age. A hematocrit
and notes a hematocrit level of level of 30% is a low level and would be reported to the health
30%. Which action should the care provider because it indicates blood loss; therefore options
nurse take? 2, 3, and 4 are incorrect.
1-Report the abnormally low
level.
, Saunders NCLEX questions
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2-Report the abnormally high
level.
3-Inform the client that the lab-
oratory result is normal.
4-Place the normal report in
the client's medical record.
4. A nurse provides dietary in- 2-Spinach
structions to a client who
will be taking warfarin sodium Warfarin sodium is an anticoagulant. Anticoagulant medica-
(Coumadin). The nurse should tions act by antagonizing the action of vitamin K, which is
tell the client to avoid which needed for clotting. When a client is taking an anticoagulant,
food item? foods high in vitamin K often are omitted from the diet. Vitamin
K-rich foods include green leafy vegetables, fish, liver, coffee,
1-Grapes and tea.
2-Spinach
3-Watermelon
4-Cottage cheese
5. A client who has been receiv- 2-Air embolism
ing total parenteral nutrition
(TPN) by way of a central ve- The signs and symptoms of air embolism include chest pain,
nous access device complains dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The
of chest pain and dyspnea. nurse also may hear a loud churning sound over the peri-
The nurse quickly assesses the cardium on auscultation of the client's chest. The signs and
client's vital signs and notes symptoms of sepsis include fever, chills, and general malaise.
that the pulse rate has in- Fluid overload causes increased intravascular volume, which
creased and the blood pres- increases the blood pressure and the pulse rate as the heart
sure has dropped. The nurse tries to pump the extra fluid volume. Fluid overload also caus-
determines that the client is es neck vein distention and shifting of fluid into the alveoli,
most likely experiencing which resulting in lung crackles. The signs and symptoms of a fluid
problem?
, Saunders NCLEX questions
Study online at https://quizlet.com/_3077wx
imbalance depend on the type of imbalance the client is ex-
1-Sepsis periencing.
2-Air embolism
3-Fluid overload
4-Fluid imbalance
6. A client who is receiving intra- 1-Infection
venous (IV) fluid therapy com- 2-Phlebitis
plains of burning and a feeling 3-Infiltration
of tightness at the IV insertion 4-Thrombosis
site. On assessment, the nurse
detects coolness and swelling An infiltrated IV line is one that has dislodged from the vein and
at the site and notes that the is lying in subcutaneous tissue. Pallor, coolness, and swelling at
IV rate has slowed. The nurse the IV site result when IV fluid is deposited in the subcutaneous
determines that which compli- tissue. When the pressure in the tissues exceeds the pressure
cation has occurred? 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 4-After maximal inspiration, hold the breath for 10 seconds
to a preoperative client about and then exhale.
the use of an incentive spirom-
eter. The nurse determines For optimal lung expansion with the incentive spirometer, the
that the client needs further in- client should assume a semi-Fowler's or high Fowler's posi-
struction if the client indicates tion. The mouthpiece should be covered completely and tightly
that he or she will take which while the client inhales slowly, with a constant flow through the
action? unit. When maximal inspiration is reached, the client should
hold the breath for 2 or 3 seconds and then exhale slowly
1-Sit upright when using the
device.
2-Inhale slowly, maintaining a
, Saunders NCLEX questions
Study online at https://quizlet.com/_3077wx
constant flow.
3-Place the lips completely
over the mouthpiece.
4-After maximal inspiration,
hold the breath for 10 seconds
and then exhale.
8. The nurse is monitoring a 2-The chest tube is functioning as expected.
client who has a closed chest
tube drainage system. The The presence of fluctuation of the fluid level in the water-seal
nurse notes fluctuation of the chamber indicates a patent drainage system. With normal
fluid level in the water-seal breathing, the water level rises with inspiration and falls with
chamber during inspiration expiration. Fluctuation stops if the tube is obstructed, if the
and expiration. On the basis of suction is not working properly, or if the lung has re-expanded.
this finding, the nurse should Options 1, 3, and 4 are incorrect interpretations of the finding.
make which interpretation? An air leak may cause excessive bubbling in the water seal
chamber. Excessive and vigorous bubbling in the suction con-
1-There is a leak in the system. trol chamber may indicate that the amount of suction needs
2-The chest tube is functioning to be decreased. The status of the dressing is not specifically
as expected. related to the presence of fluctuation of the fluid level in the
3-The amount of suction needs water-seal chamber
to be decreased.
4-The occlusive dressing at the
insertion site needs reinforce-
ment.
9. A nurse is providing morn- 1-Call the health care provider.
ing care to a client who has
a closed chest tube drainage
If the chest drainage system is dislodged from the insertion
system to treat a pneumotho-
site, the nurse immediately applies sterile gauze over the site
rax. When the nurse turns the
and calls the health care provider. The nurse would maintain
client to the side, the chest
the client in an upright position. A new chest tube system may
