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 (Q1–15) — 15 items
Q1 (SBA)
A nurse is planning morning care for an immobile postoperative
client. Which intervention has the highest priority to prevent
respiratory complications?
A. Assist the client to a chair for breakfast.
B. Teach and encourage incentive spirometer use every hour.
C. Offer a small amount of water to sip.
D. Reposition the client every 2 hours.
,Answer: B
Rationale:
• A (incorrect): Ambulation is important but may not be
immediately feasible; incentive spirometry is a direct lung
expansion strategy.
• B (correct): Incentive spirometry prevents atelectasis by
promoting deep inspiratory effort.
• C (incorrect): Hydration helps secretion mobilization but
not as direct as lung expansion.
• D (incorrect): Repositioning prevents pressure injuries and
helps lung expansion somewhat, but IS use directly
addresses alveolar inflation.
Domain: Physiological Integrity (PHI) — Application
Q2 (SATA)
Which actions should the nurse include when preparing to
insert a peripheral IV on an adult? (Select all that apply.)
A. Apply a tourniquet 10–15 cm above insertion site.
B. Cleanse insertion site with chlorhexidine for 30 seconds and
let air-dry.
C. Use a 16-gauge catheter for all adult IV starts.
D. Anchor vein distal to insertion site with nondominant hand.
E. Assess for history of mastectomy or AV fistula on the chosen
limb.
,Answer: A, B, D, E
Rationale:
• A (correct): Proper tourniquet placement helps visualize
veins; 10–15 cm is standard.
• B (correct): Chlorhexidine for ~30 seconds with drying
reduces infection risk.
• C (incorrect): Catheter gauge depends on need—16G not
for all starts (often 20–24G for routine).
• D (correct): Anchoring distal reduces vein movement and
improves success.
• E (correct): Avoid limbs with mastectomy, AV fistula, or
lymphedema.
Domain: Safe & Effective Care Environment (SECE) —
Application
Q3 (SBA)
A confused client keeps pulling at their urinary catheter. What is
the best immediate nursing action?
A. Apply wrist restraints to prevent catheter removal.
B. Encourage family to stay with the client and provide
reorientation.
C. Remove the catheter and perform intermittent
catheterization later.
, D. Secure the catheter to the client’s leg and provide
distraction.
Answer: D
Rationale:
• A (incorrect): Restraints are last resort and require orders;
not first-line.
• B (incorrect): Family presence helps, but immediate
physical security of catheter is required to prevent trauma.
• C (incorrect): Removing catheter increases infection and
retention risk; not ideal if still needed.
• D (correct): Securing catheter reduces accidental removal
and using distraction addresses agitation safely.
Domain: Psychosocial Integrity (PI) — Analysis
Q4 (SBA)
Which technique best promotes accurate apical pulse
assessment in a 78-year-old client?
A. Palpate radial pulse and count for 30 seconds, multiply by 2.
B. Auscultate at the 5th intercostal space, midclavicular line for
60 seconds.
C. Count for 15 seconds and add 4.
D. Observe chest for visible pulsations for 60 seconds.
Answer: B
Rationale:
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 (Q1–15) — 15 items
Q1 (SBA)
A nurse is planning morning care for an immobile postoperative
client. Which intervention has the highest priority to prevent
respiratory complications?
A. Assist the client to a chair for breakfast.
B. Teach and encourage incentive spirometer use every hour.
C. Offer a small amount of water to sip.
D. Reposition the client every 2 hours.
,Answer: B
Rationale:
• A (incorrect): Ambulation is important but may not be
immediately feasible; incentive spirometry is a direct lung
expansion strategy.
• B (correct): Incentive spirometry prevents atelectasis by
promoting deep inspiratory effort.
• C (incorrect): Hydration helps secretion mobilization but
not as direct as lung expansion.
• D (incorrect): Repositioning prevents pressure injuries and
helps lung expansion somewhat, but IS use directly
addresses alveolar inflation.
Domain: Physiological Integrity (PHI) — Application
Q2 (SATA)
Which actions should the nurse include when preparing to
insert a peripheral IV on an adult? (Select all that apply.)
A. Apply a tourniquet 10–15 cm above insertion site.
B. Cleanse insertion site with chlorhexidine for 30 seconds and
let air-dry.
C. Use a 16-gauge catheter for all adult IV starts.
D. Anchor vein distal to insertion site with nondominant hand.
E. Assess for history of mastectomy or AV fistula on the chosen
limb.
,Answer: A, B, D, E
Rationale:
• A (correct): Proper tourniquet placement helps visualize
veins; 10–15 cm is standard.
• B (correct): Chlorhexidine for ~30 seconds with drying
reduces infection risk.
• C (incorrect): Catheter gauge depends on need—16G not
for all starts (often 20–24G for routine).
• D (correct): Anchoring distal reduces vein movement and
improves success.
• E (correct): Avoid limbs with mastectomy, AV fistula, or
lymphedema.
Domain: Safe & Effective Care Environment (SECE) —
Application
Q3 (SBA)
A confused client keeps pulling at their urinary catheter. What is
the best immediate nursing action?
A. Apply wrist restraints to prevent catheter removal.
B. Encourage family to stay with the client and provide
reorientation.
C. Remove the catheter and perform intermittent
catheterization later.
, D. Secure the catheter to the client’s leg and provide
distraction.
Answer: D
Rationale:
• A (incorrect): Restraints are last resort and require orders;
not first-line.
• B (incorrect): Family presence helps, but immediate
physical security of catheter is required to prevent trauma.
• C (incorrect): Removing catheter increases infection and
retention risk; not ideal if still needed.
• D (correct): Securing catheter reduces accidental removal
and using distraction addresses agitation safely.
Domain: Psychosocial Integrity (PI) — Analysis
Q4 (SBA)
Which technique best promotes accurate apical pulse
assessment in a 78-year-old client?
A. Palpate radial pulse and count for 30 seconds, multiply by 2.
B. Auscultate at the 5th intercostal space, midclavicular line for
60 seconds.
C. Count for 15 seconds and add 4.
D. Observe chest for visible pulsations for 60 seconds.
Answer: B
Rationale:
