NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A client in the emergency room enters the care area to start an IV. He finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, 'my chest hurts so much!' His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the client?
Correct Answer: B
Rationale: The correct answer is B: Assess his breathing and provide oxygen if necessary. This is the first action the client should take because the patient is presenting with chest pain and difficulty breathing, which could indicate a serious medical condition like a heart attack or pulmonary embolism. By assessing the patient's breathing and providing oxygen if needed, the client can help stabilize the patient's condition and ensure proper oxygenation. Starting an IV or administering medication should come after assessing and stabilizing the patient's respiratory status. Talking with the wife, while important for gathering information, is not the priority in this situation.
Question 2 of 5
At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?
Correct Answer: C
Rationale: The correct answer is C: An 82-year-old woman who needs IV antibiotics. Checking on this client first is crucial because IV antibiotics are time-sensitive and require proper administration to ensure the effectiveness of treatment. Delaying or missing a dose can have serious consequences for the client's health. The other choices, while important, can be prioritized after attending to the client needing IV antibiotics. A: The 91-year-old man needing help eating breakfast can wait a bit longer. B: The 86-year-old man who has been incontinent can be addressed after the client needing IV antibiotics. D: The 75-year-old man recovering from an injury and needing an ice pack can also be attended to after the client requiring IV antibiotics.
Question 3 of 5
The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S's husband states, 'I don't think I can afford to refill that medication.' What is the most appropriate response of the nurse?
Correct Answer: B
Rationale: The most appropriate response of the nurse is option B: "I'll ask the physician if he can prescribe a medication that is more affordable." This response demonstrates empathy towards the husband's concerns about affordability and shows willingness to explore alternative solutions. It acknowledges the financial constraint without making assumptions about insurance coverage or suggesting a specific program like Medicare. It also shows collaboration by involving the physician in finding a suitable alternative medication. The other choices are incorrect because they do not directly address the husband's affordability concern or offer a proactive solution to the issue.
Question 4 of 5
A client has volunteered to take part in a research study. After participating for two months, he decides that he can no longer tolerate the study and decides to leave. What are the client's rights in this situation?
Correct Answer: B
Rationale: The correct answer is B: The client has a right to be released from the study without any liability. This is based on the principle of voluntary participation in research studies. Participants have the right to withdraw from a study at any time without facing any consequences or liabilities. It is essential to uphold ethical standards and respect participants' autonomy.
Choice A is incorrect because participants should not be financially penalized for withdrawing.
Choice C is incorrect as it restricts the client's future participation based on their decision to withdraw.
Choice D is incorrect as participants always retain the right to withdraw from a study voluntarily.
Question 5 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.