NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?
Correct Answer: C
Rationale: The correct answer is C: An 82-year-old woman who needs IV antibiotics. Checking on this client first is crucial because IV antibiotics are time-sensitive and require proper administration to ensure the effectiveness of treatment. Delaying or missing a dose can have serious consequences for the client's health. The other choices, while important, can be prioritized after attending to the client needing IV antibiotics. A: The 91-year-old man needing help eating breakfast can wait a bit longer. B: The 86-year-old man who has been incontinent can be addressed after the client needing IV antibiotics. D: The 75-year-old man recovering from an injury and needing an ice pack can also be attended to after the client requiring IV antibiotics.
Question 2 of 5
A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?
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.
Question 3 of 5
At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?
Correct Answer: C
Rationale: The correct answer is C: A client with COPD with an oxygen saturation of 84%. Oxygen saturation below 90% is considered critical, indicating hypoxemia in a client with COPD. Priority is given to critical physiological needs to avoid potential respiratory distress or failure.
Choices A, B, and D are important but do not pose immediate life-threatening risks. The diabetic client with a blood glucose level of 195 mg/dL can be managed with insulin administration. The family member's questions can be addressed after addressing immediate client needs. The client who requires assistance to use the bathroom can be attended to once the critical client's needs are addressed. Prioritizing based on physiological urgency ensures client safety.
Question 4 of 5
A nurse is performing an end-of-shift count of narcotics kept in the locked cabinet. The narcotic log states there should be 26 oxycodone pills left, but there are only 24 in the drawer. What is the first action of the nurse?
Correct Answer: A
Rationale: The correct answer is A: Perform the count again. The nurse should double-check the count to ensure accuracy before taking further action. Performing the count again helps to rule out any possible errors in the initial count. This step ensures that the discrepancy is not due to a simple mistake or oversight. Contacting the pharmacy (
B), checking with the last nurse who signed out narcotics (
C), or notifying the house supervisor (
D) should be done after confirming the discrepancy through a recount. The first action should always be to verify the count internally before involving external parties or escalating the issue.
Question 5 of 5
A patient is being seen in the crisis unit reporting that poison letters are coming in the mail. The patient has no history of psychiatric illness. Which group of the following medications would the patient most likely be started on?
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.