NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?
Correct Answer: C
Rationale: The correct answer is C: Fluid Volume Deficit related to post-partum hemorrhage. This nursing diagnosis is most appropriate because excessive vaginal bleeding can lead to a significant loss of blood volume, potentially resulting in hypovolemia. It is crucial to address this issue promptly to prevent further complications.
Choice A is incorrect as the primary concern is the fluid volume deficit, not knowledge deficit.
Choice B is incorrect as self-care deficit is not the priority in this situation.
Choice D is incorrect as body image disturbance is not directly related to the excessive bleeding.
Question 2 of 5
The discharge planning team is discussing plans for the dismissal of a 16-year-old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning processes but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?
Correct Answer: A
Rationale: The correct answer is A: The client is an emancipated minor. Emancipated minors are legally considered adults and have the right to make their own medical decisions without parental involvement. In this case, since the 16-year-old is emancipated, the mother's participation in discharge planning may be prohibited.
Choice B is incorrect because the mother's work schedule does not necessarily prohibit her from participating in discharge planning.
Choice C is irrelevant as the client having a job and a driver's license does not impact the mother's ability to participate.
Choice D, the mother not speaking English, may present a communication barrier but does not inherently prohibit her from participating.
Question 3 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: The correct answer is C: A client with COPD with an oxygen saturation of 84%. Oxygen saturation below 90% is considered critical, indicating hypoxemia in a client with COPD. Priority is given to critical physiological needs to avoid potential respiratory distress or failure.
Choices A, B, and D are important but do not pose immediate life-threatening risks. The diabetic client with a blood glucose level of 195 mg/dL can be managed with insulin administration. The family member's questions can be addressed after addressing immediate client needs. The client who requires assistance to use the bathroom can be attended to once the critical client's needs are addressed. Prioritizing based on physiological urgency ensures client safety.
Question 4 of 5
A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?
Correct Answer: A
Rationale: The correct initial step is to choose option A: Contact the physician to amend the order for the client. This is the most appropriate action because the conflict arises from the surgeon's policy, which can potentially be changed with physician involvement. By discussing the situation with the physician, the nurse can advocate for the family's wishes and potentially negotiate a compromise. This step prioritizes the client's and family's needs while also respecting the surgeon's authority. Options B, C, and D are not the initial steps because they involve escalating the situation before attempting direct communication with the physician, which can be seen as bypassing the appropriate chain of command.
Question 5 of 5
Which of the following types of antipsychotic medications is most likely to produce extrapyramidal effects?
Correct Answer: B
Rationale: The correct answer is B: First-generation antipsychotic drugs. These medications primarily block dopamine receptors in the brain, leading to extrapyramidal effects such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. These side effects are less common with atypical antipsychotic drugs (choice
A) due to their different receptor profiles. Third-generation antipsychotic drugs (choice
C) and dopamine system stabilizers (choice
D) are newer classes of medications with reduced extrapyramidal effects compared to first-generation drugs.
Therefore, the most likely culprit for producing extrapyramidal effects among the options provided is the first-generation antipsychotic drugs.