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
Medical–Surgical (Q1–30)
Q1 — (SBA)
Client: 68-yr with CHF, new 2-kg weight gain in 48 hrs, +2 pitting
edema bilaterally. Which is highest priority?
A. Administer furosemide PO now
B. Restrict fluids to 1,000 mL/day
C. Place on oxygen at 2 L/min via nasal cannula
D. Obtain serum potassium level
Answer: A. Administer furosemide PO now.
Domain: PI/SECE — Cognitive level: Application
,Rationale — Correct: Loop diuretic provides immediate
management for volume overload and symptomatic
improvement. A is priority to reduce preload and edema.
A: Correct — immediate treatment.
B: Incorrect — helpful long-term but not highest priority now.
C: Incorrect — no evidence of hypoxia in stem; not first action
for peripheral edema.
D: Incorrect — important before/after diuretic but not higher
priority than giving an ordered diuretic for volume overload.
Q2 — (SATA)
A postop client after abdominal surgery has the following:
shallow respirations, decreased breath sounds bases, O2 sat
91% on RA, pain 7/10. Which nursing actions are appropriate?
(Select all that apply)
A. Encourage incentive spirometry every hour while awake
B. Administer PRN opioid for pain per order
C. Ambulate early and often with assistance
D. Apply antiembolism stockings only
E. Encourage coughing and splinting incision
Answers: A, B, C, E.
Domain: PI/SECE — Cognitive level: Application
Rationale — A: Correct — improves lung expansion. B: Correct
— pain control facilitates deep breathing/ambulation. C:
Correct — reduces atelectasis and venous stasis. D: Incorrect —
stockings alone insufficient; should be combined with
,ambulation and exercises. E: Correct — prevents atelectasis;
splinting reduces pain with coughing.
Q3 — (SBA)
A client with diabetic ketoacidosis (DKA) has K+ 3.2 mEq/L.
Which is priority?
A. Start insulin infusion at prescribed rate
B. Begin potassium replacement IV per protocol
C. Obtain serum magnesium level
D. Place on telemetry
Answer: B. Begin potassium replacement IV per protocol.
Domain: PI — Cognitive level: Analysis
Rationale — Correct: Insulin shifts K+ intracellularly and can
precipitate severe hypokalemia; replace potassium before/with
insulin if low.
A: Incorrect — would further lower K+.
C: Incorrect — magnesium useful but not highest priority.
D: Incorrect — monitoring helpful but not treatment.
Q4 — (SBA)
A client with chronic atrial fibrillation is on warfarin. Which lab
value indicates warfarin is therapeutic? (Assume target INR 2.0–
3.0)
A. INR 1.4
B. INR 2.5
, C. aPTT 35 sec
D. Platelets 150,000/µL
Answer: B. INR 2.5.
Domain: PI — Cognitive level: Application
Rationale — B: Correct — within typical therapeutic range. A:
Subtherapeutic. C: Wrong test (aPTT monitors heparin). D:
Platelets not direct measure of warfarin therapeutic level.
Q5 — (Case-based — Case A)
Case A: 56-yr M with community-acquired pneumonia (CAP).
Temp 38.9°C, RR 26, BP 112/68, HR 108. Chest x-ray: right lower
lobe consolidation. ABG: PaO2 68 mmHg on RA.
Q5a (SBA) Which is initial nursing priority?
A. Start IV antibiotics as ordered
B. Administer PRN antipyretic
C. Apply oxygen to maintain SpO2 ≥ 92%
D. Encourage oral fluids
Answer: C. Apply oxygen to maintain SpO2 ≥ 92%.
Domain: PI/SECE — Cognitive: Application
Rationale — Hypoxemia requires immediate correction.
Antibiotics are essential but oxygen to correct hypoxia is highest
immediate priority.
Q5b (SBA) The MD orders ceftriaxone IV. What nursing action
before administration?
A. Assess for penicillin allergy
B. Administer with IV calcium solution
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
Medical–Surgical (Q1–30)
Q1 — (SBA)
Client: 68-yr with CHF, new 2-kg weight gain in 48 hrs, +2 pitting
edema bilaterally. Which is highest priority?
A. Administer furosemide PO now
B. Restrict fluids to 1,000 mL/day
C. Place on oxygen at 2 L/min via nasal cannula
D. Obtain serum potassium level
Answer: A. Administer furosemide PO now.
Domain: PI/SECE — Cognitive level: Application
,Rationale — Correct: Loop diuretic provides immediate
management for volume overload and symptomatic
improvement. A is priority to reduce preload and edema.
A: Correct — immediate treatment.
B: Incorrect — helpful long-term but not highest priority now.
C: Incorrect — no evidence of hypoxia in stem; not first action
for peripheral edema.
D: Incorrect — important before/after diuretic but not higher
priority than giving an ordered diuretic for volume overload.
Q2 — (SATA)
A postop client after abdominal surgery has the following:
shallow respirations, decreased breath sounds bases, O2 sat
91% on RA, pain 7/10. Which nursing actions are appropriate?
(Select all that apply)
A. Encourage incentive spirometry every hour while awake
B. Administer PRN opioid for pain per order
C. Ambulate early and often with assistance
D. Apply antiembolism stockings only
E. Encourage coughing and splinting incision
Answers: A, B, C, E.
Domain: PI/SECE — Cognitive level: Application
Rationale — A: Correct — improves lung expansion. B: Correct
— pain control facilitates deep breathing/ambulation. C:
Correct — reduces atelectasis and venous stasis. D: Incorrect —
stockings alone insufficient; should be combined with
,ambulation and exercises. E: Correct — prevents atelectasis;
splinting reduces pain with coughing.
Q3 — (SBA)
A client with diabetic ketoacidosis (DKA) has K+ 3.2 mEq/L.
Which is priority?
A. Start insulin infusion at prescribed rate
B. Begin potassium replacement IV per protocol
C. Obtain serum magnesium level
D. Place on telemetry
Answer: B. Begin potassium replacement IV per protocol.
Domain: PI — Cognitive level: Analysis
Rationale — Correct: Insulin shifts K+ intracellularly and can
precipitate severe hypokalemia; replace potassium before/with
insulin if low.
A: Incorrect — would further lower K+.
C: Incorrect — magnesium useful but not highest priority.
D: Incorrect — monitoring helpful but not treatment.
Q4 — (SBA)
A client with chronic atrial fibrillation is on warfarin. Which lab
value indicates warfarin is therapeutic? (Assume target INR 2.0–
3.0)
A. INR 1.4
B. INR 2.5
, C. aPTT 35 sec
D. Platelets 150,000/µL
Answer: B. INR 2.5.
Domain: PI — Cognitive level: Application
Rationale — B: Correct — within typical therapeutic range. A:
Subtherapeutic. C: Wrong test (aPTT monitors heparin). D:
Platelets not direct measure of warfarin therapeutic level.
Q5 — (Case-based — Case A)
Case A: 56-yr M with community-acquired pneumonia (CAP).
Temp 38.9°C, RR 26, BP 112/68, HR 108. Chest x-ray: right lower
lobe consolidation. ABG: PaO2 68 mmHg on RA.
Q5a (SBA) Which is initial nursing priority?
A. Start IV antibiotics as ordered
B. Administer PRN antipyretic
C. Apply oxygen to maintain SpO2 ≥ 92%
D. Encourage oral fluids
Answer: C. Apply oxygen to maintain SpO2 ≥ 92%.
Domain: PI/SECE — Cognitive: Application
Rationale — Hypoxemia requires immediate correction.
Antibiotics are essential but oxygen to correct hypoxia is highest
immediate priority.
Q5b (SBA) The MD orders ceftriaxone IV. What nursing action
before administration?
A. Assess for penicillin allergy
B. Administer with IV calcium solution
