NCLEX-RN
Saunders NCLEX RN Practice Questions
1. A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?
- A. Do you mean your boyfriend?
- B. Do you mean your boyfriend?
- C. No one will ever hurt you again.
- D. Tell me more about what happens when he gets angry.
Correct answer: D
Rationale: The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.
2. 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:
- A. Pulmonary embolectomy
- B. Vena caval interruption
- C. Increasing the coumadin therapy to achieve an INR of 3-4
- D. Thrombolytic therapy
Correct answer: B
Rationale: In the case of a client with a history of recurrent pulmonary embolism or contraindications to heparin, vena caval interruption may be necessary. Vena caval interruption involves placing a filter device in the inferior vena cava to prevent clots from traveling to the pulmonary circulation. Pulmonary embolectomy is a surgical procedure to remove a clot from the pulmonary artery, which is usually considered in severe or life-threatening cases. Increasing coumadin therapy to achieve a higher INR may be an option but vena caval interruption would be more appropriate in this scenario. Thrombolytic therapy is used in acute cases of pulmonary embolism to dissolve the clot rapidly, but in a recurrent case with contraindications to anticoagulants, vena caval interruption would be a preferred intervention.
3. 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?
- A. A diabetic client with a blood glucose level of 195 mg/dL
- B. A family member of an elderly client who has questions
- C. A client with COPD with an oxygen saturation of 84%
- D. A client who requires assistance to use the bathroom
Correct answer: C
Rationale: When prioritizing the needs of clients, the nurse must begin with the unstable client or manage conditions that affect airway, breathing, or circulation first. The client with COPD has a condition that affects breathing and is exhibiting decreased oxygen saturation levels; therefore, this client should be the first priority. Option A, the diabetic client with a blood glucose level of 195 mg/dL, does not present an immediate threat to airway, breathing, or circulation. Option B, addressing questions from a family member, is important but can be addressed after addressing critical patient needs. Option D, assisting a client to use the bathroom, is a routine task that can be prioritized after addressing urgent medical needs.
4. 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:
- A. Psychological abuse
- B. Abandonment
- C. Material exploitation
- D. Physical abuse
Correct answer: A
Rationale: The correct answer is A: Psychological abuse. This behavior is classified as psychological abuse, which harms another person through words or threats. The nursing assistant's actions of yelling, making threats, and using food as a form of control fall under psychological abuse. Abandonment (choice B) refers to deserting or leaving a client without care, which is not the case in the scenario. Material exploitation (choice C) involves taking advantage of a person's assets or resources for personal gain, which is not evident here. Physical abuse (choice D) involves causing physical harm, which is not the primary issue in this situation. Therefore, the most appropriate classification for the behavior described in the scenario is psychological abuse.
5. A nurse is required to float to another unit within the hospital where he is asked to care for a client on a ventilator. The nurse is uncomfortable with this assignment, as he has not had a ventilated client since nursing school. What is the nurse's most appropriate response?
- A. Explain to the nursing supervisor the level of discomfort and ask for a different assignment
- B. State that the client's needs are outside the nurse's scope of practice and request a different assignment
- C. Accept the assignment, asking for help when necessary
- D. Request to return to the home unit and send another nurse who can perform the job
Correct answer: A
Rationale: When floating to another unit and asked to take an assignment that falls outside a nurse's comfort zone, the nurse should notify the area supervisor of the level of discomfort and request a different assignment. Caring for ventilated clients typically falls within the scope of nursing practice; however, discomfort with the situation may not necessarily be overcome by accepting the assignment. Alternatively, the effects could be harmful to the client if the nurse is unfamiliar with this type of care. Requesting a different assignment is the most appropriate response in this situation, ensuring patient safety and the nurse's comfort level. Stating that the client's needs are outside the nurse's scope of practice (Choice B) may not be accurate, as caring for ventilated clients usually falls within the scope of nursing practice. Accepting the assignment (Choice C) without addressing the discomfort may compromise patient safety. Requesting to return to the home unit (Choice D) does not address the immediate need of caring for the ventilated client and may delay appropriate care.
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