NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?
Correct Answer: A
Rationale: The correct initial step is to choose option A: Contact the physician to amend the order for the client. This is the most appropriate action because the conflict arises from the surgeon's policy, which can potentially be changed with physician involvement. By discussing the situation with the physician, the nurse can advocate for the family's wishes and potentially negotiate a compromise. This step prioritizes the client's and family's needs while also respecting the surgeon's authority. Options B, C, and D are not the initial steps because they involve escalating the situation before attempting direct communication with the physician, which can be seen as bypassing the appropriate chain of command.
Question 2 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 3 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 4 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 5 of 5
A physician has written an order for '2.0 mg MS q 2-4 hr prn pain.' What is the nurse's appropriate response to this order?
Correct Answer: D
Rationale: The correct answer is D: Contact the physician to rewrite the order. The order '2.0 mg MS q 2-4 hr prn pain' is ambiguous as it does not specify the maximum dose within the 2-4 hour range. The nurse should clarify with the physician to ensure patient safety and accuracy in medication administration. Option A is incorrect as it assumes the dose without clarification. Option B is incorrect as it provides an incorrect dose. Option C is not the most appropriate initial action as contacting the physician directly is crucial.