SAUNDERS NCLEX STUDY GUIDE 2025/2026 QUESTIONS
WITH SOLUTIONS MARKED A+
✔✔The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse
should place the hands in which position to begin chest compressions? - ✔✔Chest
compressions are done by placing the hands on the lower half of the sternum. The
locations in options 2, 3, and 4 would not provide effective chest compressions.
✔✔The nurse is caring for a client who had a total knee replacement and was put on a
continuous passive motion (CPM) machine in the postanesthesia care unit (PACU).
What are some of the actions the nurse needs to monitor to operate this machine?
Select all that apply. - ✔✔While not as commonly used today, the CPM machine keeps
the prosthetic knee in motion and may prevent the formation of scar tissue which could
decrease knee mobility and increase postoperative pain. It should be used as much as
the client can tolerate. The nurse needs to make sure that the machine is well padded
and assess the client's response to the machine. Also, the machine needs to be turned
off while the client is having a meal in bed. It is very important that the nurse ensures
that the joint being moved is positioned properly on the machine. The cycle and range-
of-motion settings must be checked every 8 hours and not once a day. When the
machine is not in use, it should not be stored on the floor. If the client is confused, place
the controls to the machine out of his or her reach.
✔✔The client presents to the pediatrician's office with a temperature of 103° F for the
past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips,
enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and
enlarged nontender lymph nodes. Using situation, background, assessment, and
recommendation (SBAR communication), which statements and/or questions should the
nurse use in communication with the primary health care provider regarding this client's
condition? Select all that apply. - ✔✔Kawasaki's disease is a disease that affects the
cardiovascular system leading to fever, oropharyngeal inflammation, enlarged lymph
nodes, fissured lips, conjunctivitis, rash, peeling of palms and soles, irritability, and
aneurysms. The nurse should communicate to the provider the situation, background,
assessment, and recommendation (SBAR communication). The nurse should say, "This
client is a 4-year-old male who presented to the clinic with a temperature of 103° F for
the past 3 days. I observed this client to have conjunctivitis without discharge, cracked
lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and
enlarged nontender lymph nodes. I am concerned this client has Kawasaki's disease.
Can you please come assess this client? I think this client is at risk for aneurysm and
thrombi development and should be taken to the hospital immediately." The nurse
should not say, "It is most likely Kawasaki disease because it is the leading cause of
acquired cardiovascular disease in the U.S." Although this statement is true, it is not
necessary and should not be included in SBAR communication.
, ✔✔The nurse is caring for a client who verbalizes a need to increase her self-esteem.
Which action should the nurse plan to assist the client in achieving the goal of gaining
self-esteem?
Verbalize feelings of being unloved.
2.
Maintain a well-groomed appearance.
3.
Institute measures to prevent tooth decay.
4.
Maintain a daily diary of negative feelings. - ✔✔The client may demonstrate an
increased feeling of self-esteem through maintaining a well-groomed outward
appearance. Options 1 and 4 focus on negative issues and would be avoided. Option 3
is indirectly related to self-esteem.
✔✔A postoperative client has a prescription to receive an intravenous (IV) infusion of
1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV
infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute?
Fill in the blank. - ✔✔25 gtts/minute
Formula:
Total volume × gtt factor
------------------------- = gtt/ minute
Time in minutes
1000 mL × 105gtt/mL ------------------- = 25 gtt/min600 minutes
✔✔The nurse is reading the primary health care provider's (PHCP) documentation
regarding a pregnant client and notes that the PHCP has documented that the client
has a platypelloid pelvic shape. The nurse recognizes which characteristics to be
present in the platypelloid pelvis? Select all that apply.
1. Shallow depth
2.Wide suprapubic arch
3.Deep, curved sacral area
4.Compatible with vaginal delivery
5.Flattened anteroposteriorly and wide transversely - ✔✔A gynecoid pelvic shape is
rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal
birth. The platypelloid pelvic shape has a shallow depth, wide suprapubic arch, may be
compatible with vaginal delivery, and has a flattened anteroposterior diameter. The
gynecoid pelvis is the only pelvic type to have a deep, curved sacral area.
✔✔The nurse is monitoring a client with a diagnosis of gastric ulcer. Which finding
would indicate perforation of the ulcer? - ✔✔Perforation is a surgical emergency. It is
characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric
WITH SOLUTIONS MARKED A+
✔✔The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse
should place the hands in which position to begin chest compressions? - ✔✔Chest
compressions are done by placing the hands on the lower half of the sternum. The
locations in options 2, 3, and 4 would not provide effective chest compressions.
✔✔The nurse is caring for a client who had a total knee replacement and was put on a
continuous passive motion (CPM) machine in the postanesthesia care unit (PACU).
What are some of the actions the nurse needs to monitor to operate this machine?
Select all that apply. - ✔✔While not as commonly used today, the CPM machine keeps
the prosthetic knee in motion and may prevent the formation of scar tissue which could
decrease knee mobility and increase postoperative pain. It should be used as much as
the client can tolerate. The nurse needs to make sure that the machine is well padded
and assess the client's response to the machine. Also, the machine needs to be turned
off while the client is having a meal in bed. It is very important that the nurse ensures
that the joint being moved is positioned properly on the machine. The cycle and range-
of-motion settings must be checked every 8 hours and not once a day. When the
machine is not in use, it should not be stored on the floor. If the client is confused, place
the controls to the machine out of his or her reach.
✔✔The client presents to the pediatrician's office with a temperature of 103° F for the
past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips,
enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and
enlarged nontender lymph nodes. Using situation, background, assessment, and
recommendation (SBAR communication), which statements and/or questions should the
nurse use in communication with the primary health care provider regarding this client's
condition? Select all that apply. - ✔✔Kawasaki's disease is a disease that affects the
cardiovascular system leading to fever, oropharyngeal inflammation, enlarged lymph
nodes, fissured lips, conjunctivitis, rash, peeling of palms and soles, irritability, and
aneurysms. The nurse should communicate to the provider the situation, background,
assessment, and recommendation (SBAR communication). The nurse should say, "This
client is a 4-year-old male who presented to the clinic with a temperature of 103° F for
the past 3 days. I observed this client to have conjunctivitis without discharge, cracked
lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and
enlarged nontender lymph nodes. I am concerned this client has Kawasaki's disease.
Can you please come assess this client? I think this client is at risk for aneurysm and
thrombi development and should be taken to the hospital immediately." The nurse
should not say, "It is most likely Kawasaki disease because it is the leading cause of
acquired cardiovascular disease in the U.S." Although this statement is true, it is not
necessary and should not be included in SBAR communication.
, ✔✔The nurse is caring for a client who verbalizes a need to increase her self-esteem.
Which action should the nurse plan to assist the client in achieving the goal of gaining
self-esteem?
Verbalize feelings of being unloved.
2.
Maintain a well-groomed appearance.
3.
Institute measures to prevent tooth decay.
4.
Maintain a daily diary of negative feelings. - ✔✔The client may demonstrate an
increased feeling of self-esteem through maintaining a well-groomed outward
appearance. Options 1 and 4 focus on negative issues and would be avoided. Option 3
is indirectly related to self-esteem.
✔✔A postoperative client has a prescription to receive an intravenous (IV) infusion of
1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV
infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute?
Fill in the blank. - ✔✔25 gtts/minute
Formula:
Total volume × gtt factor
------------------------- = gtt/ minute
Time in minutes
1000 mL × 105gtt/mL ------------------- = 25 gtt/min600 minutes
✔✔The nurse is reading the primary health care provider's (PHCP) documentation
regarding a pregnant client and notes that the PHCP has documented that the client
has a platypelloid pelvic shape. The nurse recognizes which characteristics to be
present in the platypelloid pelvis? Select all that apply.
1. Shallow depth
2.Wide suprapubic arch
3.Deep, curved sacral area
4.Compatible with vaginal delivery
5.Flattened anteroposteriorly and wide transversely - ✔✔A gynecoid pelvic shape is
rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal
birth. The platypelloid pelvic shape has a shallow depth, wide suprapubic arch, may be
compatible with vaginal delivery, and has a flattened anteroposterior diameter. The
gynecoid pelvis is the only pelvic type to have a deep, curved sacral area.
✔✔The nurse is monitoring a client with a diagnosis of gastric ulcer. Which finding
would indicate perforation of the ulcer? - ✔✔Perforation is a surgical emergency. It is
characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric
