SAUNDERS NCLEX RN NGN NEWEST COMPLETE ALL 160

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Saunders NCLEX RN NGN Newest 2025/2026

SAUNDERS NCLEX RN NGN NEWEST 2025/2026 COMPLETE ALL 160

QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)

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A nurse is caring for client with increased intracranial pressure (ICP). In which position should the nurse maintain the client?

• Supine, with the head extended
• Side-lying, with the neck flexed
• Supine, with the head turned to the side

D) Head midline and elevated 30 to 45 degrees - ANSWER-Answer: D

Rationale: The client with increased ICP should be positioned with the head in a neutral midline position. It is the responsibility of the nurse to ensure that all those delivering care to the client maintain the proper positioning. The client should avoid flexing or extending the neck or turning the neck side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positioning promotes venous drainage from the cranium to keep ICP down.

A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should:

• Assess the clear fluid for protein
• Check the clear fluid for the presence of glucose
• Place cotton balls or dry gauze loosely in the ears
• Use an otoscope to assess the tympanic membrane for rupture - ANSWER-Answer: B

Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because it will separate into bloody and yellow concentric rings on dressing material, a phenomenon referred to as the halo sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF indicates a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze, or an otoscope into the ear puts the client at risk for infection.

A nurse is caring for a client who has just undergone cardioversion. Which of the following interventions is the nurse's priority after this procedure? 1 / 4

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• Administering oxygen
• Monitoring the blood pressure
• Administering antidysrhythmic medications

D) Monitoring the client's level of consciousness - ANSWER-Answer: A

Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and detection of dysrhythmias. The priority nursing intervention here is administering oxygen.

A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1C) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. The nurse tells the client that this test is used

specifically to:

• Detect diabetic complications
• Assess long-term glycemic control
• Determine whether the client is at risk for hypoglycemia
• Determine whether the prescribed insulin dosage is adequate - ANSWER-Answer: B

Rationale: The HbA1C reading provides an indication of glycemic control over the preceding 3 months. An HbA1C value of less than 7% indicates good glycemic control. When increases in the blood glucose occur, some glucose molecules attach themselves to red blood cells (RBCs) and remain there for the life of the RBCs. Therefore a high value on this test is correlated with a high blood glucose level, indicating poor long-term control of blood glucose, which often leads to the development of complications in the client with diabetes mellitus. The other options are not purposes for this test.

A nurse caring for a client with AIDS is monitoring the client for signs of complications. Which of the following findings would cause the nurse to suspect infection with Pneumocystis jiroveci?Select all that apply.

• Diarrhea
• Tachypnea
• Pedal edema 2 / 4

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• Intermittent fever
• Dyspnea when ambulating

F) Expectoration of frothy mucus - ANSWER-Answer(s): B, D, E

Rationale: Pneumocystis jiroveci pneumonia is a very common and severe opportunistic infection affecting the client with AIDS. Clinical manifestations include dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, weight loss, and tachypnea. Persons with advanced disease may exhibit crackles, decreased breath sounds, and cyanosis. Diarrhea and pedal edema are not associated with this infection.

Zidovudine (AZT, Retrovir) is prescribed for a client with AIDS. The nurse tells the client that it is

important to report back to the clinic as scheduled for follow-up:

• Blood glucose checks
• Blood pressure checks
• Complete blood counts (CBCs)

D) Electrocardiographic (ECG) studies - ANSWER-Answer: C

Rationale: Zidovudine is an antiviral medication. Common side effects include

agranulocytopenia and anemia. The nurse carefully monitors CBC results for these changes.With early infection or in the client who is asymptomatic, a CBC is usually performed monthly for 3 months, then every 3 months thereafter. In clients with advanced disease, a CBC is usually performed every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. This medication does not affect the blood glucose level, blood pressure, or cardiac status.

After a nonimmunocompromised client undergoes a Mantoux test for tuberculosis (TB) infection, an area of induration 6 mm wide develops. The client asks the nurse what this result

means. The nurse's best response is:

• "We'll have to repeat the test, because the result is inconclusive."
• "The swollen area is small, so that means your test result is negative."
• "You've been exposed to tuberculosis, so you'll need to have a chest x-ray." 3 / 4

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• "You need to get started on medication right away, because you've got tuberculosis." -

ANSWER-Answer: B

Rationale: An area of induration of less than 10 mm is considered a negative result. An area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection in a client without immunosuppressive disease indicates exposure to and possible infection with TB. A reaction of 5 mm or greater is considered positive in immunocompromised individuals. A positive reaction does not mean that active disease is present but instead indicates exposure to TB or the presence of inactive (dormant) TB. Further testing, including a chest x-ray and sputum culture, would be required if the reaction were positive.

A client's arterial blood gases (ABGs) are analyzed: pH 7.49, Paco2 31 mm Hg, Pao2 97 mm Hg, HCO3- 22 mEq/L. Which of the following acid-base disturbances does the nurse identify from these results?

• Metabolic acidosis
• Metabolic alkalosis
• Respiratory acidosis

D) Respiratory alkalosis - ANSWER-Answer: D

Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the Paco2 is greater than 45 mm Hg; respiratory alkalosis is present when the Paco2 is less than 35 mm Hg. Metabolic acidosis is present when the HCO3- is less than 22 mEq/L; metabolic alkalosis is present when the HCO3- is greater than 26 mEq/L. This client's ABG results are consistent with respiratory alkalosis.

A client has just been found to have deep vein thrombosis (DVT) of the right leg. Which of the following interventions does the nurse immediately implement?

• Elevating the foot of the bed 6 inches
• Placing ice packs on and under the right leg
• Documenting the need for hourly calf measurements
• Performing passive range-of-motion exercises of the right leg - ANSWER-Answer: A

Rationale: Standard therapy for DVT consists of bed rest, leg elevation, and application of warm, moist heat to the affected leg. Elevation of the legs decreases venous pressure, which in turn

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