NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
Which of the following is an example of a living will?
Correct Answer: C
Rationale: The correct answer is C because a living will is a legal document that outlines a person's preferences for medical treatment in case they are unable to communicate their wishes. In this case, the client's instruction not to be resuscitated through chest compressions if his heart stops beating is an example of a living will. This choice specifically addresses medical treatment preferences during a critical health situation.
Choices A, B, and D are incorrect because they all involve decisions or instructions that pertain to events or actions after the client's death, rather than specifying medical treatment preferences while the client is alive.
Choice A involves appointing someone to make healthcare decisions, choice B involves designating inheritance of property, and choice D involves specifying burial or cremation services. These choices do not align with the purpose of a living will, which is to provide guidance for medical treatment decisions during the client's lifetime.
Question 2 of 5
Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?
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.
Question 3 of 5
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
Correct Answer: A
Rationale: The correct answer is A: Unequal leg length. In developmental dysplasia of the hip, there is abnormal development of the hip joint. This can lead to unequal leg lengths due to hip instability and dislocation. Limited adduction may be present due to hip joint abnormalities. Diminished femoral pulses are not typically associated with developmental dysplasia of the hip. Symmetrical gluteal folds are usually present in healthy infants.
Question 4 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 5 of 5
Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?
Correct Answer: D
Rationale: The most appropriate action for the nurse in this scenario is to contact the physical therapy department again and repeat the order (
Choice
D). This is the correct answer because it directly addresses the issue of the consult not being completed within a reasonable timeframe. By contacting the department again, the nurse ensures that the order is not overlooked or forgotten. This action shows proactive communication and follow-up to expedite the process and ensure the client receives the necessary care in a timely manner.
The other choices are incorrect:
A: Calling the supervisor and filing a complaint is premature without first attempting to resolve the issue directly with the department.
B: Contacting the physician is not the nurse's role in this situation. The focus should be on coordinating with the appropriate department.
C: Assessing the client's activity level is important but does not address the primary issue of the physical therapy consult not being completed.
Overall, choice D is the most appropriate course of action in this scenario.