Saunders NCLEX RN Practice Questions

Extract:

Question 1 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 2 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.

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?

A. A statement explaining the condition the client was found in, quoting the client's words about the situation B. An explanation of how the fall happened and when the physician was notified C. An account of the conditions of the room that contributed to the client's fall D. A summary of the client's medical history and current medications

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

At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?

A. A 91-year-old man who needs help eating breakfast B. An 86-year-old man who has been incontinent in his bed C. An 82-year-old woman who needs IV antibiotics D. A 75-year-old man who is recovering from an injury and needs an ice pack

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 5 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.

Saunders NCLEX RN Practice Questions - Nurselytic

Nurselytic

NCLEX-RN

NCLEX-RN