Saunders NCLEX RN Practice Questions - Nurselytic

Correct Answer: A

Rationale: The correct answer is A because whistle-blowing involves reporting unethical or illegal behavior within an organization to higher authorities. In this scenario, the nurse is reporting a colleague's misuse of supplies for personal gain, which is unethical.
Choice B involves a client suing a nurse for malpractice, not whistle-blowing.
Choice C is a standard response to a client falling and does not involve reporting unethical behavior.
Choice D describes a case of neglect, not whistle-blowing.

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: 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: A

Rationale: The correct answer is A because whistle-blowing involves reporting unethical or illegal behavior within an organization to higher authorities. In this scenario, the nurse is reporting a colleague's misuse of supplies for personal gain, which is unethical.
Choice B involves a client suing a nurse for malpractice, not whistle-blowing.
Choice C is a standard response to a client falling and does not involve reporting unethical behavior.
Choice D describes a case of neglect, not whistle-blowing.

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.