Saunders NCLEX RN Practice Questions - Nurselytic

Correct Answer: B

Rationale: The correct answer is B: What is the issue that I can solve for this client? When formulating a nursing diagnosis, the nurse should focus on identifying the client's actual or potential health problems that can be addressed through nursing interventions. This question helps the nurse to pinpoint the specific problem or need that requires nursing attention, leading to the development of an effective care plan.
A: Focusing on the physician's diagnosis is not relevant to formulating a nursing diagnosis.
C: Physician orders are important but not directly related to formulating a nursing diagnosis.
D: Identifying the underlying disease is important but not the primary focus when formulating a nursing diagnosis.

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.

Correct Answer: C

Rationale: The correct answer is C: Randomized controlled trial (RCT). In an RCT, participants are randomly assigned to either the intervention group or the control group, ensuring that both groups are similar at the start of the trial. This minimizes bias and allows for comparing the outcomes of the intervention group with the control group. This design helps establish a cause-effect relationship between the intervention and the outcomes.


Choice A (Experimental design) is not specific enough as there are various types of experimental designs.
Choice B (Double-blind experiment) refers to a study where neither the participants nor the researchers know who is receiving the intervention, which is not the case here.
Choice D (Repeated measures design) involves measuring the same participants at different time points, not separating them into different groups.

Correct Answer: A

Rationale: The correct answer is A: The approximate length of the surgery. This is the priority topic to instruct the client on admission because knowing the duration of the surgery helps manage the client's expectations and anxiety levels. Understanding the length of the procedure also allows the client to plan for post-operative care and recovery.


Choice B: The type of anticoagulants is important but not as critical on admission as knowing the surgery duration.
Choice C: The time of the next meal is important for preoperative fasting but not as crucial as understanding the surgery length.
Choice D: The length of time until the client can return to work is important, but it is a secondary concern compared to the immediate surgical procedure.

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.