NCLEX-RN
NCLEX RN Practice Questions With Rationale Questions
Extract:
Question 1 of 5
Albert is a patient in the hospital who is scheduled for surgery the following morning. After the pre-operative visit from the anesthesia staff member who has obtained surgical consent, Albert asks for an explanation of what type of surgery he is going to have. He states that he's not sure what he just signed. What is your best response?
Correct Answer: C
Rationale: The correct response is to ensure that the patient fully understands the nature of the surgery they are about to undergo. If the patient expresses uncertainty about the procedure they signed consent for, it indicates a lack of informed consent, which is essential before any surgery. By requesting the nurse anesthetist to return and provide a more detailed explanation, the patient can make an informed decision.
Choices A, B, and D do not address the issue of the patient's lack of understanding and the need for informed consent, making them incorrect. Option C is the best course of action to rectify the situation and ensure the patient's understanding and consent are properly obtained.
Question 2 of 5
A victim of a gunshot wound to the abdomen has been admitted to the hospital, accompanied by a police officer. When questioned, the officer states that the patient is a suspect in a homicide, which occurred as part of the same incident. A small child was killed as the result of a stray bullet. The patient is combative, yells that he's in pain and demands medication. What is your most appropriate response?
Correct Answer: C
Rationale: The most appropriate and caring response is to perform a pain assessment and administer the pain medication that has been ordered. Regardless of personal feelings about any given situation, the nurse's responsibility is to provide unbiased, appropriate, and supportive care, as stated in the American Nurses Association (AN
A) Code of Ethics.
Choice A is not appropriate as it disregards the patient's immediate need for pain relief.
Choice B may escalate the situation and is not the priority in this case.
Choice D is not the immediate action needed to address the patient's pain and distress.
Question 3 of 5
You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT:
Correct Answer: C
Rationale: Discharge instructions for a patient with newly diagnosed multiple sclerosis should focus on promoting safety and minimizing exacerbations. Hot baths should be avoided as excessive heat can trigger acute symptoms.
Therefore, instructions may include PT referral for an exercise program to maintain mobility, avoidance of prolonged sun exposure to prevent symptom exacerbation, and guidance to evaluate the home environment for safety as symptoms progress. Hot baths are not recommended due to the risk of exacerbating symptoms, making it the correct answer.
Choices A, B, and D are appropriate for a patient with multiple sclerosis, as they address mobility, symptom management, and safety concerns, respectively.
Question 4 of 5
A woman has died as a result of a motor vehicle accident. She is listed as an organ donor, and her family is considering whether to comply with her wishes. Which of the following is true?
Correct Answer: D
Rationale: In cases where a deceased person is listed as an organ donor, the family may have the final say on whether to proceed with organ donation, even if the individual had expressed their wish to donate. Physicians may prioritize the emotional well-being of the family over the wishes of the deceased, especially if organ donation could cause additional distress or trauma to the grieving family members.
Therefore, it is possible for physicians to respect the family's decision not to proceed with organ donation, even if the deceased had previously expressed the desire to donate. This decision-making process underscores the importance of considering and respecting the perspectives and emotions of both the deceased individual and their surviving family members in organ donation scenarios.
Question 5 of 5
Rachel is a 48-year-old mother of three who has been admitted after a drug overdose in a failed suicide attempt. When she regains consciousness, she states that she is ashamed and embarrassed that she tried to take her own life. What is the most therapeutic response to Rachel's statement?
Correct Answer: D
Rationale: The most therapeutic response to Rachel's statement is to provide non-judgmental support and hope. By acknowledging the patient's feelings of shame and embarrassment and offering help and understanding, the nurse can help Rachel maintain her self-esteem.
Choice A is not therapeutic as it may unintentionally convey guilt or further shame.
Choice B is judgmental and confrontational, which can create a barrier to open communication.
Choice C is dismissive and does not address Rachel's emotional state. The correct response (
Choice
D) acknowledges the patient's struggle, offers support, and conveys empathy, aligning with the nurse's role to treat all patients with respect and dignity in challenging situations.