NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?
Correct Answer: A
Rationale: The correct answer is A: A 26-year-old woman who had a bowel resection. This choice is appropriate for the Women's Health Center as it aligns with the specialization of the unit in women's health. The patient's condition is surgical in nature, which can be managed effectively in a women's health unit that likely has the necessary resources and expertise to care for post-surgical patients.
Choice B: A 40-year-old man who underwent a hernia repair, is incorrect because it is not aligned with the specialization of the Women's Health Center.
Choice C: A 31-year-old woman with septicemia and on a ventilator, is incorrect because this patient requires intensive care and support beyond what a women's health unit can provide.
Choice D: A 91-year-old man with Alzheimer's disease recovering from a fall, is incorrect because this patient's needs are more aligned with geriatric care rather than women's health.
Question 2 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 3 of 5
When taking Mr. D's blood pressure, the first sound you hear is at 162, and the second sound you hear is at 86. You should document and report that the blood pressure is _____________.
Correct Answer: C
Rationale: The correct answer is C: 162/86. The first sound heard corresponds to the systolic pressure (top number) and the second sound heard corresponds to the diastolic pressure (bottom number).
Therefore, the blood pressure is documented as systolic/diastolic. In this case, the first sound at 162 indicates the systolic pressure, and the second sound at 86 indicates the diastolic pressure. Alternatives A (86/162) is incorrect as systolic pressure always comes first. B (irregular and high) is incorrect as the blood pressure values are within normal range. Option D (normal for people of all ages) is incorrect because the blood pressure should be documented as per standard practice, regardless of age.
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
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
Correct Answer: A
Rationale: The correct answer is A because giving away cherished possessions can be a sign of preparing for suicide. This behavior may indicate a lack of concern for material possessions due to a belief that they won't be needed in the future.
Choice B shows anger and isolation, not necessarily suicidal ideation.
Choice C demonstrates anger but no indication of suicidal thoughts.
Choice D shows anger towards the roommate, not self-harm intentions.