NCLEX RN Practice Questions With Rationale

Extract:

Question 1 of 5

At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, "My blood pressure is usually much lower."? The nurse should tell the client to:

Correct Answer: A

Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke.
Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (
Choice
B) or a week (
Choice
D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (
Choice
C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.

Question 2 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?

A. Don't worry, they'll explain it in the operating room. B. It's standard procedure to get the consent; you don't need to worry. C. Let me ask the nurse anesthetist to come back and explain it further. D. Someone will review it with you prior to surgery.

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 3 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?

A. The woman would have had to list herself as an organ donor and notify her family before her death that she has considered donating her organs. B. The Uniform Anatomical Gift Act requires the physician caring for the patient to inform the family who receives the donor organs. C. Physicians can choose to go against the deceased's wishes if the family decides that organ donation is not an acceptable choice. D. Physicians have the legal responsibility to inform patients of the risks involved in donating organs.

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 4 of 5

A 3-year-old pediatric patient's mother would like to stay at the patient's bedside throughout the night as the patient seems calmer when she is present. What is the most caring and appropriate response?

A. Reinforce visiting hours B. Allow her to stay for a short period beyond normal hours C. Allow her to stay throughout the night D. Offer to get bedding for a couch in the waiting room

Correct Answer: C

Rationale: Allowing the mother to stay throughout the night is the most caring and appropriate response in this situation. Pediatric facilities often recognize the crucial role parents play in their child's care and are supportive of unlimited visitation. Allowing the mother to stay can help maintain the child's calmness and enhance the bond between the family and healthcare team. Reinforcing visiting hours (
Choice
A) may not address the specific needs of this situation where the child benefits from the mother's presence. Allowing her to stay for a short period beyond normal hours (
Choice
B) may not fully address the need for her continuous presence. Offering to get bedding for a couch in the waiting room (
Choice
D) may not be necessary if the mother can stay with her child in the patient's room.

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?

A. It's a relief your children weren't left without a mother. B. What were you thinking? C. We're here to help patients who value life. D. I know life can be difficult. We're here to help you.

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.

NCLEX RN Practice Questions With Rationale - Nurselytic

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