NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
Which of the following tasks may be delegated to unlicensed assistive personnel?
Correct Answer: C
Rationale: The correct answer is C. Assisting with performing incentive spirometry can be delegated to unlicensed assistive personnel (UAP) as it involves a non-invasive procedure that does not require specialized training or licensure. UAP can help patients with using the incentive spirometer to improve lung function under the supervision of a licensed healthcare provider.
Choices A, B, and D involve tasks that require specific skills and knowledge to prevent complications, hence should be performed by licensed healthcare professionals.
Question 2 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 3 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.
Question 4 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 5 of 5
The discharge planning team is discussing plans for the dismissal of a 16-year-old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning processes but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?
Correct Answer: A
Rationale: The correct answer is A: The client is an emancipated minor. Emancipated minors are legally considered adults and have the right to make their own medical decisions without parental involvement. In this case, since the 16-year-old is emancipated, the mother's participation in discharge planning may be prohibited.
Choice B is incorrect because the mother's work schedule does not necessarily prohibit her from participating in discharge planning.
Choice C is irrelevant as the client having a job and a driver's license does not impact the mother's ability to participate.
Choice D, the mother not speaking English, may present a communication barrier but does not inherently prohibit her from participating.