NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
Which of the following may be a cultural barrier that impacts a healthcare provider's ability to provide care or education to the client?
Correct Answer: C
Rationale: The correct answer is C because using pantomime to explain a procedure to a deaf client is a cultural barrier. Deaf individuals may use sign language or have different communication preferences, so relying solely on pantomime may not effectively convey the necessary information. This can lead to misunderstandings or incomplete communication, impacting the quality of care provided.
Choice A is incorrect as offering materials at an 8th-grade reading level is a best practice in health literacy and not a cultural barrier.
Choice B may reflect cultural preferences but does not necessarily impede the provider's ability to provide care.
Choice D involves a client's spiritual beliefs but does not directly hinder the provider's ability to provide care.
Question 2 of 5
A patient diagnosed with a mild anxiety disorder has been referred to treatment in a community mental health center. Treatment most likely provided by the center includes
Correct Answer: A
Rationale: The correct answer is A: Medical management of symptoms. In mild anxiety disorders, medication like SSRIs or benzodiazepines are commonly used to alleviate symptoms. Psychotherapy may be helpful but is not daily. Constant staff supervision is not necessary for mild cases. Psychological stabilization is too broad and not specific to treatment.
Question 3 of 5
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the healthcare provider ordering:
Correct Answer: B
Rationale: The correct answer is B: Vena caval interruption. In this scenario, the client has a history of recurrent pulmonary embolism, indicating a high risk for further episodes. Vena caval interruption, such as with an inferior vena cava filter, is a preventive measure to reduce the risk of pulmonary embolism recurrence by trapping blood clots before they reach the pulmonary circulation. This intervention is indicated when anticoagulation alone is not sufficient to prevent further emboli. Pulmonary embolectomy (
A) is a surgical procedure to remove a clot from the pulmonary artery and is typically reserved for massive, life-threatening embolisms. Increasing coumadin therapy (
C) to achieve a higher INR may increase bleeding risk without necessarily preventing future emboli. Thrombolytic therapy (
D) is reserved for acute, large emboli causing hemodynamic instability.
Question 4 of 5
A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?
Correct Answer: B
Rationale: The correct answer is B: Review the state scope of practice standards for nurses. This is the appropriate response as it allows the nurse to understand her legal boundaries and responsibilities. By reviewing the state scope of practice standards, the nurse can ensure she is acting within the limits of her licensure and avoid potential legal or ethical issues.
Choice A is incorrect because reporting the offense to the state board of nursing licensure should not be the initial response without first verifying the scope of practice standards.
Choice C is incorrect as it does not address the issue of the nurse operating outside her scope of practice.
Choice D is incorrect as the house supervisor may not have the necessary knowledge of the nurse's scope of practice.
Question 5 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.