Saunders NCLEX RN Practice Questions - Nurselytic

Correct Answer: B

Rationale: The correct answer is B: Review the state scope of practice standards for nurses. This is the appropriate response as it allows the nurse to understand her legal boundaries and responsibilities. By reviewing the state scope of practice standards, the nurse can ensure she is acting within the limits of her licensure and avoid potential legal or ethical issues.


Choice A is incorrect because reporting the offense to the state board of nursing licensure should not be the initial response without first verifying the scope of practice standards.
Choice C is incorrect as it does not address the issue of the nurse operating outside her scope of practice.
Choice D is incorrect as the house supervisor may not have the necessary knowledge of the nurse's scope of practice.

Correct Answer: C

Rationale: The correct answer is C: Fluid Volume Deficit related to post-partum hemorrhage. This nursing diagnosis is most appropriate because excessive vaginal bleeding can lead to a significant loss of blood volume, potentially resulting in hypovolemia. It is crucial to address this issue promptly to prevent further complications.
Choice A is incorrect as the primary concern is the fluid volume deficit, not knowledge deficit.
Choice B is incorrect as self-care deficit is not the priority in this situation.
Choice D is incorrect as body image disturbance is not directly related to the excessive bleeding.

Correct Answer: A

Rationale: The correct answer is A: Aripiprazole (Abilify). In this scenario, the patient is experiencing paranoid delusions, a symptom commonly associated with psychotic disorders. Aripiprazole is an atypical antipsychotic that is often used to treat symptoms of psychosis, including delusions. It is a preferred choice because it has a lower risk of side effects compared to typical antipsychotics like fluphenazine. Risperidone, another atypical antipsychotic, could also be considered, but aripiprazole is often preferred due to its side effect profile. Fluoxetine, an antidepressant, is not the ideal choice for treating psychotic symptoms.
Therefore, aripiprazole is the most appropriate medication in this case.

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.

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.