Saunders NCLEX RN Practice Questions

Extract:

Question 1 of 5

A client asks a nurse, 'Do you think I should move back home after this procedure?' and the nurse responds by saying, 'Do you think you should move back home?' What type of therapeutic communication is the nurse representing?

Correct Answer: B

Rationale: The correct answer is B: Reflection. Reflection involves paraphrasing the client's words to help them explore their feelings and thoughts. In this scenario, the nurse is reflecting the client's question back to them, encouraging self-exploration. Observation (
A) involves stating what the nurse sees or hears without interpretation. Summarizing (
C) involves condensing information. Validating (
D) involves confirming the client's feelings or experiences. The nurse's response does not align with the other options, making reflection the best choice.

Question 2 of 5

Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?

A. Taking a health history and performing a physical exam prior to the procedure B. Instructing the client about how to care for his colostomy stoma C. Developing goals that state the client will ambulate three times a day D. Determining that the client may need more support at home after dismissal

Correct Answer: B

Rationale: The correct answer is B. Instructing the client about how to care for his colostomy stoma is an example of the intervention phase as it involves providing specific guidance to the client on post-operative care. This intervention directly addresses the client's needs post-colostomy and helps promote optimal healing and adjustment.

Choice A is part of the assessment phase, which occurs before the intervention phase.
Choice C involves goal-setting, which is part of the planning phase.
Choice D pertains to discharge planning, which is part of the evaluation phase.

In summary,
Choice B is the correct answer because it aligns with the intervention phase of the nursing care plan, focusing on providing necessary education and support to the client regarding colostomy care.

Question 3 of 5

Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?

A. Collect and organize documents for the client's medical record B. Prepare the client's identification bracelet C. Identify pertinent health history data and current needs and limitations D. Gather the client's valuables and secure them in a locked container

Correct Answer: C

Rationale: The correct answer is C because identifying pertinent health history data and current needs and limitations is crucial in developing an individualized care plan for the stroke patient. This data helps determine the appropriate interventions and therapies needed for the client's recovery. Collecting and organizing documents (choice
A) can be important but not the primary action. Preparing an identification bracelet (choice
B) and gathering valuables (choice
D) are important tasks but not the immediate priority upon admission.

Question 4 of 5

Which example best describes a nurse who exhibits moral courage?

A. A nurse feels angry when a parent refuses important treatment for his child. B. A nurse considers seeking help for depression when she feels she cannot meet the needs of her clients in the oncology unit. C. A nurse contacts a physician for further orders when he fails to order comfort measures for a client with a terminal illness. D. A nurse is frustrated when the laboratory is slow in responding to an order for a stat blood glucose.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates moral courage by advocating for the client's well-being in the face of potential conflict with the physician. By taking action to ensure the comfort of a terminally ill client, the nurse upholds ethical principles.
Choice A reflects emotional response, not moral courage.
Choice B focuses on personal issues, not professional courage.
Choice D involves frustration, not moral courage.

Question 5 of 5

Which of the following is an example of whistle-blowing?

A. A nurse contacts administration about a colleague who takes supplies to use for a mission trip B. A client sues a nurse because she failed to call the physician about his wound infection C. A nursing assistant calls for help when a client falls out of bed D. A client developed a sacral pressure ulcer when he was not turned in bed for over four hours

Correct Answer: A

Rationale: The correct answer is A because whistle-blowing involves reporting unethical or illegal behavior within an organization to higher authorities. In this scenario, the nurse is reporting a colleague's misuse of supplies for personal gain, which is unethical.
Choice B involves a client suing a nurse for malpractice, not whistle-blowing.
Choice C is a standard response to a client falling and does not involve reporting unethical behavior.
Choice D describes a case of neglect, not whistle-blowing.

Saunders NCLEX RN Practice Questions - Nurselytic

Nurselytic

NCLEX-RN

NCLEX-RN