Saunders NCLEX RN Practice Questions - Nurselytic

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.

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.

Correct Answer: C

Rationale: The correct answer is C because using eye contact and maintaining an open stance while the client is talking demonstrates active listening. Eye contact shows attentiveness and respect, while an open stance conveys empathy and receptiveness. This non-verbal communication encourages the client to feel heard and understood, fostering a therapeutic relationship.


Choice A is incorrect because using humor may not always align with the client's feelings or be perceived as appropriate.
Choice B is incorrect as restating what the client said is a form of paraphrasing, not active listening.
Choice D is incorrect because providing personal information can shift the focus away from the client's needs and may breach professional boundaries.

Correct Answer: B

Rationale: The correct answer is B: First-generation antipsychotic drugs. These medications primarily block dopamine receptors in the brain, leading to extrapyramidal effects such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. These side effects are less common with atypical antipsychotic drugs (choice
A) due to their different receptor profiles. Third-generation antipsychotic drugs (choice
C) and dopamine system stabilizers (choice
D) are newer classes of medications with reduced extrapyramidal effects compared to first-generation drugs.
Therefore, the most likely culprit for producing extrapyramidal effects among the options provided is the first-generation antipsychotic drugs.

Correct Answer: C

Rationale: The correct answer is C because using pantomime to explain a procedure to a deaf client is a cultural barrier. Deaf individuals may use sign language or have different communication preferences, so relying solely on pantomime may not effectively convey the necessary information. This can lead to misunderstandings or incomplete communication, impacting the quality of care provided.


Choice A is incorrect as offering materials at an 8th-grade reading level is a best practice in health literacy and not a cultural barrier.
Choice B may reflect cultural preferences but does not necessarily impede the provider's ability to provide care.
Choice D involves a client's spiritual beliefs but does not directly hinder the provider's ability to provide care.