Saunders NCLEX RN Practice Questions - Nurselytic

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Saunders NCLEX RN Practice Questions Questions

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Question 1 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 2 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.

Question 3 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 4 of 5

The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S's husband states, 'I don't think I can afford to refill that medication.' What is the most appropriate response of the nurse?

Correct Answer: B

Rationale: The most appropriate response of the nurse is option B: "I'll ask the physician if he can prescribe a medication that is more affordable." This response demonstrates empathy towards the husband's concerns about affordability and shows willingness to explore alternative solutions. It acknowledges the financial constraint without making assumptions about insurance coverage or suggesting a specific program like Medicare. It also shows collaboration by involving the physician in finding a suitable alternative medication. The other choices are incorrect because they do not directly address the husband's affordability concern or offer a proactive solution to the issue.

Question 5 of 5

What is involved in obtaining informed consent?

Correct Answer: A

Rationale: The correct answer is A because obtaining informed consent involves providing the client with an explanation of the reasons for the procedure. This ensures that the client understands the purpose, risks, benefits, and alternatives of the procedure before giving consent.
Choice B is incorrect because a signature on a form alone does not guarantee informed consent.
Choice C is incorrect as affirming liability is not a necessary component of obtaining informed consent.
Choice D is incorrect as it combines an essential element (
A) with an incorrect element (
C).

Similar Questions

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A client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?
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?
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

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