NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Question 1 of 5
When taking Mr. D's blood pressure, the first sound you hear is at 162, and the second sound you hear is at 86. You should document and report that the blood pressure is _____________.
Correct Answer: C
Rationale: You should document and report that the blood pressure measurement for Mr. D is 162/86. The first sound heard corresponds to the systolic reading (top number), and the second sound corresponds to the diastolic reading (bottom number). Blood pressure readings are not irregular; irregularities are typically associated with pulses. The blood pressure recorded is not normal for individuals of all ages; it is considered high.
Question 2 of 5
In which situation might an occupational health nurse consultation be necessary?
Correct Answer: A
Rationale: An occupational health nurse is involved in assessing the work environment, educating employees about safety practices, and infection control. When a nurse sustains an injury due to incorrect body mechanics, it falls under the purview of an occupational health nurse because they are responsible for documenting such incidents, providing necessary care or treatment, and ensuring that preventive measures are in place to avoid similar accidents in the future. The other options do not directly relate to the role of an occupational health nurse. Testifying in court, assisting a client with rehabilitation, or implementing a new electronic health record system are not typical scenarios where an occupational health nurse would be involved.
Question 3 of 5
Which of the following is the most appropriate example of anticipatory guidance for a 16-year-old who has been hospitalized for an ankle fracture?
Correct Answer: B
Rationale: Anticipatory guidance is an educational process that provides information important to a client's situation. When considering a 16-year-old who has been hospitalized for an ankle fracture, the most suitable anticipatory guidance would be regarding driving and staying safe. This guidance is crucial as it is age-appropriate and relevant to preventing future injuries. Choices A, C, and D are less pertinent in this scenario. Changes associated with puberty, health hazards of smoking, and social media influences may not directly address the immediate safety concerns of a 16-year-old with an ankle fracture.
Question 4 of 5
At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?
Correct Answer: C
Rationale: When prioritizing the needs of clients, the nurse must begin with the unstable client or manage conditions that affect airway, breathing, or circulation first. The client with COPD has a condition that affects breathing and is exhibiting decreased oxygen saturation levels; therefore, this client should be the first priority. Option A, the diabetic client with a blood glucose level of 195 mg/dL, does not present an immediate threat to airway, breathing, or circulation. Option B, addressing questions from a family member, is important but can be addressed after addressing critical patient needs. Option D, assisting a client to use the bathroom, is a routine task that can be prioritized after addressing urgent medical needs.
Question 5 of 5
Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?
Correct Answer: D
Rationale: In this situation, the most appropriate action for the nurse to take is to contact the physical therapy department again and repeat the order. It is crucial to ensure that the client receives the necessary care as prescribed. Following up with the department reinforces the importance of the order and increases the likelihood of prompt action. Option A is incorrect because escalating the situation to filing a complaint should be a last resort after all other communication attempts have failed. Option B is not the best course of action as the first step should be to ensure proper communication within the healthcare team. Option C is not the priority in this scenario, as the immediate concern is to address the delay in the physical therapy consult.