NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?
Correct Answer: C
Rationale: The correct answer is C because identifying pertinent health history data and current needs and limitations is crucial in developing an individualized care plan for the stroke patient. This data helps determine the appropriate interventions and therapies needed for the client's recovery. Collecting and organizing documents (choice
A) can be important but not the primary action. Preparing an identification bracelet (choice
B) and gathering valuables (choice
D) are important tasks but not the immediate priority upon admission.
Question 2 of 5
Which example best describes a nurse who exhibits moral courage?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates moral courage by advocating for the client's well-being in the face of potential conflict with the physician. By taking action to ensure the comfort of a terminally ill client, the nurse upholds ethical principles.
Choice A reflects emotional response, not moral courage.
Choice B focuses on personal issues, not professional courage.
Choice D involves frustration, not moral courage.
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 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 nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:
Correct Answer: A
Rationale: The correct answer is A: Psychological abuse. This behavior involves verbal threats and emotional manipulation, causing fear and distress to the client. It violates the client's rights and dignity. Abandonment (
B) refers to deserting a client in need. Material exploitation (
C) involves misuse of a client's property or resources. Physical abuse (
D) involves causing harm through physical force.