SAUNDERS NCLEX QUESTIONS AND
VERIFIED ANSWERS WELL GRADED
(NEW 2025/2026 UPDATE)
QUESTIONS WITH VERIFIED
ANSWERS 100% /A+ GRADE
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. -
CORRECT ANSWER-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.
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 - CORRECT ANSWER-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?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - CORRECT ANSWER-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? -
CORRECT ANSWER-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.
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. - CORRECT ANSWER-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
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. - CORRECT ANSWER-2-The chest tube is functioning
as expected.
VERIFIED ANSWERS WELL GRADED
(NEW 2025/2026 UPDATE)
QUESTIONS WITH VERIFIED
ANSWERS 100% /A+ GRADE
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. -
CORRECT ANSWER-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.
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 - CORRECT ANSWER-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?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - CORRECT ANSWER-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? -
CORRECT ANSWER-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.
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. - CORRECT ANSWER-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
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. - CORRECT ANSWER-2-The chest tube is functioning
as expected.
