NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?
Correct Answer: B
Rationale: The correct answer is B: Take the client into a private room. This is the most appropriate action because it ensures the client's privacy and confidentiality, which is crucial in cases of suspected domestic violence. By placing the client in a private room, the nurse can establish a safe and secure environment for the client to disclose sensitive information and receive proper care. This approach also helps to build trust with the client and allows for a thorough assessment of injuries without compromising the client's dignity.
Choice A is incorrect because asking the client to undress immediately may further traumatize the client and violate her privacy.
Choice C is not the nurse's immediate responsibility; the priority is to ensure the client's safety and well-being.
Choice D is also not the most appropriate action as it does not directly address the client's immediate needs.
Question 2 of 5
Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?
Correct Answer: D
Rationale: The most appropriate action for the nurse in this scenario is to contact the physical therapy department again and repeat the order (
Choice
D). This is the correct answer because it directly addresses the issue of the consult not being completed within a reasonable timeframe. By contacting the department again, the nurse ensures that the order is not overlooked or forgotten. This action shows proactive communication and follow-up to expedite the process and ensure the client receives the necessary care in a timely manner.
The other choices are incorrect:
A: Calling the supervisor and filing a complaint is premature without first attempting to resolve the issue directly with the department.
B: Contacting the physician is not the nurse's role in this situation. The focus should be on coordinating with the appropriate department.
C: Assessing the client's activity level is important but does not address the primary issue of the physical therapy consult not being completed.
Overall, choice D is the most appropriate course of action in this scenario.
Question 3 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?
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 4 of 5
When taking Mr. D's blood pressure, the first sound you hear is at 162, and the second sound you hear is at 86. You should document and report that the blood pressure is _____________.
Correct Answer: C
Rationale: The correct answer is C: 162/86. The first sound heard corresponds to the systolic pressure (top number) and the second sound heard corresponds to the diastolic pressure (bottom number).
Therefore, the blood pressure is documented as systolic/diastolic. In this case, the first sound at 162 indicates the systolic pressure, and the second sound at 86 indicates the diastolic pressure. Alternatives A (86/162) is incorrect as systolic pressure always comes first. B (irregular and high) is incorrect as the blood pressure values are within normal range. Option D (normal for people of all ages) is incorrect because the blood pressure should be documented as per standard practice, regardless of age.
Question 5 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.