Saunders NCLEX Questions and
Answers | Latest Version | 2025/2026 |
Correct & Verified
A client with pneumonia is experiencing shortness of breath and O₂ saturation of 88%. Which
action should the nurse take first?
a. Administer prescribed antibiotics
✔✔b. Place the client in high-Fowler’s position and provide supplemental oxygen
c. Encourage coughing exercises
d. Offer fluids
**Rationale:** Oxygenation and airway management take priority over medication
administration.
A nurse is preparing to administer digoxin. Which assessment finding requires holding the dose?
a. BP 130/78 mmHg
b. Apical pulse 75 bpm
✔✔c. Apical pulse 48 bpm
d. Respiratory rate 20 breaths/min
**Rationale:** Digoxin can cause bradycardia; medication is held if HR <60 bpm.
1
,A client reports burning sensation while urinating. Which intervention should the nurse
implement first?
a. Encourage fluids
b. Administer prescribed antibiotic
✔✔c. Obtain a urine sample for culture and sensitivity
d. Teach about cranberry juice
**Rationale:** Confirming infection guides appropriate treatment before interventions.
A postoperative client is confused, restless, and diaphoretic. Which assessment should the nurse
perform first?
a. Pain assessment
✔✔b. Vital signs and oxygen saturation
c. Wound inspection
d. Neuro check
**Rationale:** Confusion and diaphoresis may indicate hypoxia or shock; ABCs are priority.
A client is scheduled for surgery and reports not signing the consent form. What should the nurse
do?
2
,✔✔a. Notify the surgeon immediately
b. Explain the procedure in detail
c. Ask the family to sign
d. Document the report
**Rationale:** Only the surgeon can obtain informed consent; nurse’s role is to alert them.
A client with heart failure develops sudden shortness of breath, crackles in the lungs, and pink
frothy sputum. Which action is priority?
a. Encourage deep breathing
✔✔b. Apply oxygen and notify provider immediately
c. Elevate the legs
d. Administer diuretic later
**Rationale:** Pulmonary edema is life-threatening; oxygen and provider notification are
urgent.
A client on a PCA pump has a respiratory rate of 8 breaths/min. Which action should the nurse
take first?
a. Administer additional analgesic
b. Reposition the client
3
, ✔✔c. Stop the PCA and assess airway and oxygenation
d. Encourage deep breathing
**Rationale:** Respiratory depression is a priority; analgesia must be paused.
A nurse is caring for multiple clients. Which client should be assessed first?
a. Client asking for morning bath
✔✔b. Client with O₂ sat 84% on room air and dyspnea
c. Client with mild headache
d. Client due for routine labs
**Rationale:** Hypoxemia requires immediate intervention.
A client reports chest pain radiating to the jaw and left arm. Which is the priority action?
a. Administer acetaminophen
✔✔b. Assess vital signs, ECG, and oxygen saturation
c. Offer fluids
d. Reposition the client
**Rationale:** Chest pain with radiation may indicate myocardial infarction; assessment
precedes all other actions.
4
Answers | Latest Version | 2025/2026 |
Correct & Verified
A client with pneumonia is experiencing shortness of breath and O₂ saturation of 88%. Which
action should the nurse take first?
a. Administer prescribed antibiotics
✔✔b. Place the client in high-Fowler’s position and provide supplemental oxygen
c. Encourage coughing exercises
d. Offer fluids
**Rationale:** Oxygenation and airway management take priority over medication
administration.
A nurse is preparing to administer digoxin. Which assessment finding requires holding the dose?
a. BP 130/78 mmHg
b. Apical pulse 75 bpm
✔✔c. Apical pulse 48 bpm
d. Respiratory rate 20 breaths/min
**Rationale:** Digoxin can cause bradycardia; medication is held if HR <60 bpm.
1
,A client reports burning sensation while urinating. Which intervention should the nurse
implement first?
a. Encourage fluids
b. Administer prescribed antibiotic
✔✔c. Obtain a urine sample for culture and sensitivity
d. Teach about cranberry juice
**Rationale:** Confirming infection guides appropriate treatment before interventions.
A postoperative client is confused, restless, and diaphoretic. Which assessment should the nurse
perform first?
a. Pain assessment
✔✔b. Vital signs and oxygen saturation
c. Wound inspection
d. Neuro check
**Rationale:** Confusion and diaphoresis may indicate hypoxia or shock; ABCs are priority.
A client is scheduled for surgery and reports not signing the consent form. What should the nurse
do?
2
,✔✔a. Notify the surgeon immediately
b. Explain the procedure in detail
c. Ask the family to sign
d. Document the report
**Rationale:** Only the surgeon can obtain informed consent; nurse’s role is to alert them.
A client with heart failure develops sudden shortness of breath, crackles in the lungs, and pink
frothy sputum. Which action is priority?
a. Encourage deep breathing
✔✔b. Apply oxygen and notify provider immediately
c. Elevate the legs
d. Administer diuretic later
**Rationale:** Pulmonary edema is life-threatening; oxygen and provider notification are
urgent.
A client on a PCA pump has a respiratory rate of 8 breaths/min. Which action should the nurse
take first?
a. Administer additional analgesic
b. Reposition the client
3
, ✔✔c. Stop the PCA and assess airway and oxygenation
d. Encourage deep breathing
**Rationale:** Respiratory depression is a priority; analgesia must be paused.
A nurse is caring for multiple clients. Which client should be assessed first?
a. Client asking for morning bath
✔✔b. Client with O₂ sat 84% on room air and dyspnea
c. Client with mild headache
d. Client due for routine labs
**Rationale:** Hypoxemia requires immediate intervention.
A client reports chest pain radiating to the jaw and left arm. Which is the priority action?
a. Administer acetaminophen
✔✔b. Assess vital signs, ECG, and oxygen saturation
c. Offer fluids
d. Reposition the client
**Rationale:** Chest pain with radiation may indicate myocardial infarction; assessment
precedes all other actions.
4
