NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the healthcare provider ordering:
Correct Answer: B
Rationale: The correct answer is B: Vena caval interruption. In this scenario, the client has a history of recurrent pulmonary embolism, indicating a high risk for further episodes. Vena caval interruption, such as with an inferior vena cava filter, is a preventive measure to reduce the risk of pulmonary embolism recurrence by trapping blood clots before they reach the pulmonary circulation. This intervention is indicated when anticoagulation alone is not sufficient to prevent further emboli. Pulmonary embolectomy (
A) is a surgical procedure to remove a clot from the pulmonary artery and is typically reserved for massive, life-threatening embolisms. Increasing coumadin therapy (
C) to achieve a higher INR may increase bleeding risk without necessarily preventing future emboli. Thrombolytic therapy (
D) is reserved for acute, large emboli causing hemodynamic instability.
Question 2 of 5
The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?
Correct Answer: A
Rationale: The correct answer is A: A 26-year-old woman who had a bowel resection. This choice is appropriate for the Women's Health Center as it aligns with the specialization of the unit in women's health. The patient's condition is surgical in nature, which can be managed effectively in a women's health unit that likely has the necessary resources and expertise to care for post-surgical patients.
Choice B: A 40-year-old man who underwent a hernia repair, is incorrect because it is not aligned with the specialization of the Women's Health Center.
Choice C: A 31-year-old woman with septicemia and on a ventilator, is incorrect because this patient requires intensive care and support beyond what a women's health unit can provide.
Choice D: A 91-year-old man with Alzheimer's disease recovering from a fall, is incorrect because this patient's needs are more aligned with geriatric care rather than women's health.
Question 3 of 5
A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?
Correct Answer: A
Rationale: The correct answer is A because documenting the client's own words provides direct evidence of their condition and thought process at the time of the incident. This helps in understanding the client's perspective and decision-making, which is crucial for providing appropriate care and preventing future falls.
Choice B is incorrect because while it may be important to document how the fall happened and when the physician was notified, it does not directly capture the client's own words and thoughts.
Choice C is incorrect as it focuses on the conditions of the room rather than the client's own account of the situation.
Choice D is also incorrect as it pertains to the client's medical history and medications, which are important but not directly relevant to documenting the client's immediate situation and actions.
Question 4 of 5
According to HIPAA, which of the following is considered an individual right for privacy of a client's protected health information?
Correct Answer: A
Rationale: The correct answer is A: The right to receive a copy of the organization's privacy practices. This is because under HIPAA, individuals have the right to be informed about how their protected health information is being used and disclosed. Providing clients with a copy of the organization's privacy practices ensures transparency and empowers them to understand their rights regarding their health information.
Choices B, C, and D are incorrect:
B: The right to receive medical bills for care received - This is not a specific right related to privacy of protected health information under HIPAA.
C: The right to change personal health information - Individuals have the right to request amendments to their health information, but this is not directly related to privacy rights.
D: An understanding that protected health information will only be used in regards to client treatments - While this is an important principle under HIPAA, it does not specifically address individual rights related to privacy practices.
Question 5 of 5
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the healthcare provider ordering:
Correct Answer: B
Rationale: The correct answer is B: Vena caval interruption. In this scenario, the client has a history of recurrent pulmonary embolism, indicating a high risk for further episodes. Vena caval interruption, such as with an inferior vena cava filter, is a preventive measure to reduce the risk of pulmonary embolism recurrence by trapping blood clots before they reach the pulmonary circulation. This intervention is indicated when anticoagulation alone is not sufficient to prevent further emboli. Pulmonary embolectomy (
A) is a surgical procedure to remove a clot from the pulmonary artery and is typically reserved for massive, life-threatening embolisms. Increasing coumadin therapy (
C) to achieve a higher INR may increase bleeding risk without necessarily preventing future emboli. Thrombolytic therapy (
D) is reserved for acute, large emboli causing hemodynamic instability.