SAUNDERS COMPREHENSIVE

REVIEW FOR NCLEX FIVE

1) A child with an autism spectrum disorder (ASD) is being

admitted to the hospital for diagnostic tests. Which room

assignment is the most appropriate for the child?

 Private room

2) The labor and delivery room nurse has just received reports

on 4 clients. After reviewing the client data, the nurse

should assess which client first?

 A client who has just received an

intravenous loading dose of magnesium sulfate to

stop preterm labor

3) The nurse has developed a teaching plan for a client with

hypertension regarding the administration of prescribed

medications. What is the initial nursing action?

 Assess the client's readiness to learn.

4) A client with cancer is receiving intravenous morphine

sulfate for pain. When writing the plan of care for this

client, the nurse should include which action as the

priority action?

 Monitor respiratory status.

5) The nurse is preparing to suction the airway of a client

who has a tracheostomy tube and gathers the supplies needed

for the procedure. In order of priority, which actions

should the nurse take to perform this procedure? Arrange

the actions in the order that they should be performed. All

options must be used.

 1) Place the client in a semi Fowler's

position.

 2) Turn on the suction device and set the

regulator at 80 mm Hg.

 3) Attach the suction tubing to the suction

catheter.

FROM 4143 TO 5142

 4) Hyperoxygenate the client.

 5) Insert the catheter into the tracheostomy

until resistance is met, and then pull it back 1

cm.

 6) Apply intermittent suction and slowly

withdraw the catheter while rotating it back and

forth.

6) The nurse notes blanching, coolness, and edema at a

client's peripheral intravenous (IV) site. Which nursing

action is the priority?

 Remove the IV catheter.

7) A client has a prescription to begin an infusion of 1000 mL

of 5% dextrose in lactated Ringer's solution. The client

has an intravenous (IV) cannula inserted, and the nurse

prepares the solution and IV tubing. Arrange the actions in

the order that they should be performed. All options must

be used.

 1) Close the roller clamp on the IV tubing.

 2) Spike the IV bag and half-fill the drip

chamber.

 3) Open the roller clamp and fill the tubing.

 4) Uncap the distal end of the tubing.

 5) Attach the distal end of the tubing to the

client.

8) The nurse is caring for 4 pediatric clients. After

receiving reports from the night shift, which child should

the nurse assess first?

 A 6-week-old infant admitted to the hospital

for decreased level of consciousness; shaken baby

syndrome is suspected

9) The nurse is assigned to 4 clients on a postoperative

surgical unit at a rural hospital. When prioritizing the

care, the nurse recognizes that the highest priority is

focused on which client?

 The client with problems clearing the airway

related to abdominal incision pain

FROM 4143 TO 5142

10) The emergency department nurse is caring for a child

with suspected epiglottitis and has ensured that the child

has a patent airway. Which action is the next priority in

the care of this child?

 Prepare the child for a chest radiograph.

11) The nursing instructor asks the nursing student to

identify the priorities of care for an assigned client. The

nursing instructor determines that the nursing student

understands the client's needs when which statement is

made?

 "Actual or life-threatening concerns are the

priority."

12) A hospitalized client with type 1 diabetes mellitus

received Humulin N and Humulin R insulin 2 hours ago (at

7:30 a.m.). The client calls the nurse and reports that he

is feeling hungry, shaky, and weak. The client ate

breakfast at 8 a.m. and is due to eat lunch at noon.

Arrange the actions that the nurse will take in the order

that they should be performed. All options must be used.

 1) Check the client's blood glucose level.

 2) Give the client ½ cup (118 mL) of fruit

juice to drink.

 3) Take the client's vital signs.

 4) Retest the blood glucose level.

 5) Give the client a small snack of

carbohydrate and protein.

 6) Document the client's complaints, actions

taken, and outcome.

13) An emergency department nurse is preparing to receive

4 clients as a result of a motor vehicle crash. Which

victim should the nurse attend to first?

 A 45-year-old man with chest pain, shortness

of breath, and diaphoresis

14) The nurse is assigned to care for 4 clients. Which

client should the nurse assess first?

FROM 4143 TO 5142

 A client who has a peripheral (index finger)

oxygen saturation percentage of 85%

15) The nurse has received her client assignment for the

day. Which client should the nurse care for first?

 A client with postoperative pain reported at

7 out of 10, with 10 being the worst

16) The nurse has received the client assignment for the

day. Which client should the nurse care for first?

 The client admitted with the medical

diagnosis of neutropenia who is afebrile and is

complaining of pain with urination

17) The nurse is the first responder at the scene of a 6-

car crash on a highway. Which victim should the nurse

attend to first?

 A victim experiencing dyspnea

18) The nurse in charge of a nursing unit is asked to

select the hospitalized clients who can be discharged so

that hospital beds can be made available for victims of a

community disaster. Which clients can be safely discharged?

Select all that apply.

 A client with a Holter monitor

 A client receiving oral antibiotics

 A client experiencing sinus rhythm

19) The nurse has received her client assignment for the

day. Which client should the nurse check first?

 A client who has just returned from surgery

20) The nurse is a responder at the scene of a building

collapse. Which victim should the nurse care for first?

 Victim with an apparent chest wall defect

and asymmetrical chest wall movement