Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
INTEGRATED REVIEW — COMPREHENSIVE NCLEX
PRACTICE PACK [FUNDAMENTALS,
PHARMACOLOGY, MEDICAL-SURGICAL,
MATERNITY, PEDIATRIC, EMERGENCY, AND
SPECIALTY SYSTEMS] TEST BANK
Fundamentals / Safe & Effective Care Environment (15 items)
1 (SBA — Prioritization / Management of Care)
A nurse on a medical floor has these four patients at the start of
the shift:
A. 48-yr with pneumonia, 92% SpO₂ on 2 L NC, ambulating with
assistance.
B. 72-yr postop hip replacement POD1, new atrial fibrillation
with rate 135/min, on telemetry.
C. 60-yr with diabetic foot infection receiving IV antibiotics,
,reports new onset chest discomfort.
D. 35-yr postop appendectomy stable, requesting pain med.
Which patient should the nurse assess first?
Answer: C. 60-yr with diabetic foot infection reporting chest
discomfort.
Rationale:
• A: Hypoxia but stable on 2 L and ambulating — important
but not immediately life-threatening.
• B: New rapid Afib concerning, but chest discomfort (C)
suggests possible cardiac ischemia — higher immediate
risk.
• C (correct): Chest discomfort may indicate myocardial
ischemia — requires immediate assessment and possible
transfer to higher level care.
• D: Stable postop pain — lower priority.
2 (SATA — Safety / Infection Control)
Which of the following actions by the nurse are appropriate
when caring for a patient with suspected pulmonary TB? (Select
all that apply.)
A. Place the patient in a negative-pressure airborne isolation
room.
B. Wear an N95 respirator (or higher) when entering the room.
C. Use surgical mask for all visitors while in the room.
,D. Start airborne precautions only after AFB smear returns
positive.
E. Teach patient to cover mouth/nose when coughing.
Answer: A, B, C, E.
Rationale:
• A (correct): Airborne precautions require negative-
pressure isolation.
• B (correct): N95 is required for airborne pathogens.
• C (correct): Visitors should wear surgical masks at a
minimum; for TB, N95 recommended for prolonged
exposure—facility policy may vary.
• D: Incorrect — begin airborne precautions immediately
with suspected TB, do not wait for smear.
• E (correct): Cough etiquette reduces droplet spread.
3 (SBA — Delegation)
Which task is appropriate to delegate to an experienced
unlicensed assistive personnel (UAP) caring for a medically
stable adult?
A. Administer oral antibiotic.
B. Reinforce discharge teaching about wound care.
C. Assist with ambulation and record orthostatic vitals.
D. Perform admission head-to-toe assessment.
, Answer: C. Assist with ambulation and record orthostatic
vitals.
Rationale:
• A: Medication administration is RN responsibility.
• B: Teaching—complex and requires RN judgment. UAP may
reinforce simple instructions but initial teaching is RN role.
• C (correct): UAP can assist with mobility and take vitals
within scope.
• D: Admission assessment requires RN clinical judgment.
4 (SBA — Documentation / Legal)
A nurse documents a patient’s report: “Patient states, ‘I feel like
dying.’” Which documentation is best?
A. Patient depressed; suicidal ideation.
B. Patient states, “I feel like dying.” Notify provider.
C. Patient verbalized feeling depressed today.
D. Patient refusing medications.
Answer: B. Patient states, “I feel like dying.” Notify provider.
Rationale:
• A: Interpretation without quotation marks—adds inference
(suicidal ideation) without assessed evidence.
• B (correct): Objective quote plus action taken (notify
provider) is accurate and defensible.
PN® Examination
9th Edition
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
INTEGRATED REVIEW — COMPREHENSIVE NCLEX
PRACTICE PACK [FUNDAMENTALS,
PHARMACOLOGY, MEDICAL-SURGICAL,
MATERNITY, PEDIATRIC, EMERGENCY, AND
SPECIALTY SYSTEMS] TEST BANK
Fundamentals / Safe & Effective Care Environment (15 items)
1 (SBA — Prioritization / Management of Care)
A nurse on a medical floor has these four patients at the start of
the shift:
A. 48-yr with pneumonia, 92% SpO₂ on 2 L NC, ambulating with
assistance.
B. 72-yr postop hip replacement POD1, new atrial fibrillation
with rate 135/min, on telemetry.
C. 60-yr with diabetic foot infection receiving IV antibiotics,
,reports new onset chest discomfort.
D. 35-yr postop appendectomy stable, requesting pain med.
Which patient should the nurse assess first?
Answer: C. 60-yr with diabetic foot infection reporting chest
discomfort.
Rationale:
• A: Hypoxia but stable on 2 L and ambulating — important
but not immediately life-threatening.
• B: New rapid Afib concerning, but chest discomfort (C)
suggests possible cardiac ischemia — higher immediate
risk.
• C (correct): Chest discomfort may indicate myocardial
ischemia — requires immediate assessment and possible
transfer to higher level care.
• D: Stable postop pain — lower priority.
2 (SATA — Safety / Infection Control)
Which of the following actions by the nurse are appropriate
when caring for a patient with suspected pulmonary TB? (Select
all that apply.)
A. Place the patient in a negative-pressure airborne isolation
room.
B. Wear an N95 respirator (or higher) when entering the room.
C. Use surgical mask for all visitors while in the room.
,D. Start airborne precautions only after AFB smear returns
positive.
E. Teach patient to cover mouth/nose when coughing.
Answer: A, B, C, E.
Rationale:
• A (correct): Airborne precautions require negative-
pressure isolation.
• B (correct): N95 is required for airborne pathogens.
• C (correct): Visitors should wear surgical masks at a
minimum; for TB, N95 recommended for prolonged
exposure—facility policy may vary.
• D: Incorrect — begin airborne precautions immediately
with suspected TB, do not wait for smear.
• E (correct): Cough etiquette reduces droplet spread.
3 (SBA — Delegation)
Which task is appropriate to delegate to an experienced
unlicensed assistive personnel (UAP) caring for a medically
stable adult?
A. Administer oral antibiotic.
B. Reinforce discharge teaching about wound care.
C. Assist with ambulation and record orthostatic vitals.
D. Perform admission head-to-toe assessment.
, Answer: C. Assist with ambulation and record orthostatic
vitals.
Rationale:
• A: Medication administration is RN responsibility.
• B: Teaching—complex and requires RN judgment. UAP may
reinforce simple instructions but initial teaching is RN role.
• C (correct): UAP can assist with mobility and take vitals
within scope.
• D: Admission assessment requires RN clinical judgment.
4 (SBA — Documentation / Legal)
A nurse documents a patient’s report: “Patient states, ‘I feel like
dying.’” Which documentation is best?
A. Patient depressed; suicidal ideation.
B. Patient states, “I feel like dying.” Notify provider.
C. Patient verbalized feeling depressed today.
D. Patient refusing medications.
Answer: B. Patient states, “I feel like dying.” Notify provider.
Rationale:
• A: Interpretation without quotation marks—adds inference
(suicidal ideation) without assessed evidence.
• B (correct): Objective quote plus action taken (notify
provider) is accurate and defensible.
