Saunders NCLEX-RN Review Fundamentals of
Nursing Test Bank Questions and Answers Latest
Versions 2025
The nurse is assessing a client's postoperative pain using
the PQRSTU method. Using this method, which questions
would the nurse ask the client? Select all that apply.
"Where is the pain located?"
"Does pain medication help?"
"What does the pain feel like?"
"How does the pain affect you?"
"Do you have the pain when you sleep?"
"What makes your pain better or worse?"
"Where is the pain located?"
"What does the pain feel like?"
"How does the pain affect you?"
"What makes your pain better or worse?"
Rationale:
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.
,A nurse is checking lochia discharge in a woman in the
immediate postpartum period. The nurse notes that the
lochia is bright red and contains some small clots. Based on
this data, the nurse should make which interpretation?
The client is hemorrhaging.
The client needs to increase oral fluids.
The client is experiencing normal lochia discharge.
The client's health care provider needs to be notified of the
finding.
The client is experiencing normal lochia discharge.
Rationale:
Lochia, the uterine discharge present after birth, initially is bright
red and may contain small clots. During the first 2 hours after
birth, the amount of uterine discharge should be approximately
that of a heavy menstrual period. After that time, the lochial flow
should steadily decrease, and the color of the discharge should
change to a pinkish red or reddish brown. Because this is a
normal, expected occurrence, options 1, 2, and 4 are incorrect.
A nurse is assessing a woman in the second trimester of
pregnancy who was admitted to the maternity unit with a
suspected diagnosis of abruptio placentae. Which finding
would the nurse expect to note if abruptio placentae is
present?
Soft uterus
Abdominal pain
Nontender uterus
,Painless vaginal bleeding
Abdominal pain
Rationale:
Classic signs and symptoms of abruptio placentae include vaginal
bleeding, abdominal pain, and uterine tenderness and
contractions. Mild to severe uterine hypertonicity is present. Pains
is mild to severe and either localized or diffuse over one region of
the uterus, with a board-like abdomen. Painless vaginal bleeding
and a soft, nontender uterus in the second or third trimester of
pregnancy are signs of placenta previa.
A nurse in the labor room is caring for a client who is in the
first stage of labor. On assessing the fetal patterns, the nurse
notes an early deceleration of the fetal heart rate (FHR) on
the monitor strip. Based on this finding, which is the
appropriate nursing action?
Contact the health care provider.
Place the mother in a Trendelenburg position.
Administer oxygen to the client by face mask.
Document the findings and continue to monitor fetal
patterns.
Document the findings and continue to monitor fetal patterns.
Rationale:
Early deceleration of the FHR refers to a gradual decrease in the
heart rate, followed by a return to baseline, in response to
compression of the fetal head. It is a normal and benign finding.
Because early decelerations are considered benign, interventions
, are not necessary. Therefore, options 1, 2, and 3 are
unnecessary.
A woman in the third trimester of pregnancy with a diagnosis
of mild preeclampsia is being monitored at home. The home
care nurse teaches the woman about the signs that need to
be reported to the health care provider. The nurse should tell
the woman to call the health care provider if which occurs?
Urine tests negative for protein.
Fetal movements are more than four per hour.
Weight increases by more than 1 pound in a week.
The blood pressure reading is ranging between 122/80 and
132/88 mm Hg.
Weight increases by more than 1 pound in a week.
Rationale:
The nurse would instruct the client to report any increase in blood
pressure, protein in the urine, weight gain greater than 1 pound
per week, or edema. The client also is taught how to count fetal
movements and is instructed that decreased fetal activity (three or
fewer movements per hour) may indicate fetal compromise and
should be reported.
A woman in the third trimester of pregnancy visits the clinic
for a scheduled prenatal appointment. The woman tells the
nurse that she frequently has leg cramps, primarily when she
is reclining. Once thrombophlebitis has been ruled out, the
nurse should tell the woman to implement which measure to
alleviate the leg cramps?
Apply heat to the affected area.
Nursing Test Bank Questions and Answers Latest
Versions 2025
The nurse is assessing a client's postoperative pain using
the PQRSTU method. Using this method, which questions
would the nurse ask the client? Select all that apply.
"Where is the pain located?"
"Does pain medication help?"
"What does the pain feel like?"
"How does the pain affect you?"
"Do you have the pain when you sleep?"
"What makes your pain better or worse?"
"Where is the pain located?"
"What does the pain feel like?"
"How does the pain affect you?"
"What makes your pain better or worse?"
Rationale:
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.
,A nurse is checking lochia discharge in a woman in the
immediate postpartum period. The nurse notes that the
lochia is bright red and contains some small clots. Based on
this data, the nurse should make which interpretation?
The client is hemorrhaging.
The client needs to increase oral fluids.
The client is experiencing normal lochia discharge.
The client's health care provider needs to be notified of the
finding.
The client is experiencing normal lochia discharge.
Rationale:
Lochia, the uterine discharge present after birth, initially is bright
red and may contain small clots. During the first 2 hours after
birth, the amount of uterine discharge should be approximately
that of a heavy menstrual period. After that time, the lochial flow
should steadily decrease, and the color of the discharge should
change to a pinkish red or reddish brown. Because this is a
normal, expected occurrence, options 1, 2, and 4 are incorrect.
A nurse is assessing a woman in the second trimester of
pregnancy who was admitted to the maternity unit with a
suspected diagnosis of abruptio placentae. Which finding
would the nurse expect to note if abruptio placentae is
present?
Soft uterus
Abdominal pain
Nontender uterus
,Painless vaginal bleeding
Abdominal pain
Rationale:
Classic signs and symptoms of abruptio placentae include vaginal
bleeding, abdominal pain, and uterine tenderness and
contractions. Mild to severe uterine hypertonicity is present. Pains
is mild to severe and either localized or diffuse over one region of
the uterus, with a board-like abdomen. Painless vaginal bleeding
and a soft, nontender uterus in the second or third trimester of
pregnancy are signs of placenta previa.
A nurse in the labor room is caring for a client who is in the
first stage of labor. On assessing the fetal patterns, the nurse
notes an early deceleration of the fetal heart rate (FHR) on
the monitor strip. Based on this finding, which is the
appropriate nursing action?
Contact the health care provider.
Place the mother in a Trendelenburg position.
Administer oxygen to the client by face mask.
Document the findings and continue to monitor fetal
patterns.
Document the findings and continue to monitor fetal patterns.
Rationale:
Early deceleration of the FHR refers to a gradual decrease in the
heart rate, followed by a return to baseline, in response to
compression of the fetal head. It is a normal and benign finding.
Because early decelerations are considered benign, interventions
, are not necessary. Therefore, options 1, 2, and 3 are
unnecessary.
A woman in the third trimester of pregnancy with a diagnosis
of mild preeclampsia is being monitored at home. The home
care nurse teaches the woman about the signs that need to
be reported to the health care provider. The nurse should tell
the woman to call the health care provider if which occurs?
Urine tests negative for protein.
Fetal movements are more than four per hour.
Weight increases by more than 1 pound in a week.
The blood pressure reading is ranging between 122/80 and
132/88 mm Hg.
Weight increases by more than 1 pound in a week.
Rationale:
The nurse would instruct the client to report any increase in blood
pressure, protein in the urine, weight gain greater than 1 pound
per week, or edema. The client also is taught how to count fetal
movements and is instructed that decreased fetal activity (three or
fewer movements per hour) may indicate fetal compromise and
should be reported.
A woman in the third trimester of pregnancy visits the clinic
for a scheduled prenatal appointment. The woman tells the
nurse that she frequently has leg cramps, primarily when she
is reclining. Once thrombophlebitis has been ruled out, the
nurse should tell the woman to implement which measure to
alleviate the leg cramps?
Apply heat to the affected area.
