NCLEX-RN
Saunders NCLEX RN Practice Questions
1. A client in the emergency room enters the care area to start an IV. He finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, 'my chest hurts so much!' His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the client?
- A. Bring the IV kit and quickly start an IV
- B. Assess his breathing and provide oxygen, if necessary
- C. Administer medication to control chest pain
- D. Talk with his wife and find out why she is crying
Correct answer: B
Rationale: In the above scenario, the first action of the nurse should be to assess the client's airway and breathing. It is crucial to address respiratory status first, as the client appears to be experiencing difficulty breathing. Providing oxygen if necessary can help support oxygenation and alleviate potential respiratory distress. Administering medication for chest pain or starting an IV can come after ensuring adequate oxygenation. Talking with the client's wife, though important for emotional support, is not the priority when the client's respiratory status needs to be assessed and managed promptly.
2. During a health history assessment of a new patient, which data should be the focus for patient teaching?
- A. Age and gender
- B. Saturated fat intake
- C. Hispanic/Latino ethnicity
- D. Family history of diabetes
Correct answer: B
Rationale: The correct answer is saturated fat intake. Behaviors play a crucial role in health outcomes, and saturated fat intake is a modifiable behavior that can significantly impact a patient's health. By focusing on educating the patient about reducing saturated fat intake, the healthcare provider can empower the patient to make positive changes. While age, gender, ethnicity, and family history are important factors in understanding a patient's health status, they are not behaviors that can be directly modified through patient teaching. Therefore, these factors are essential for developing an individualized care plan but are not the primary focus of patient teaching. Saturated fat intake directly relates to dietary habits, which can be altered through education and support to promote better health outcomes.
3. Which of the following statements is true regarding non-profit organizations?
- A. They are located in various areas, not specifically poor or rural ones.
- B. They are mandated to care for people, even if clients are unable to pay for services.
- C. The money they receive for services is reinvested back into their own business to further develop services.
- D. They are not referred to as proprietary organizations.
Correct answer: B
Rationale: Non-profit organizations are entities that operate for a social cause or public benefit, and they do not distribute profits to owners or shareholders. They are not limited to being located in poor or rural areas; they can be found in various locations. One key characteristic of non-profits is that they are obligated to provide services, regardless of a client's ability to pay. This ensures that essential services are accessible to all individuals in need. The statement 'The money they receive for services is reinvested back into their own business to further develop services' is correct. Non-profit organizations reinvest any surplus funds back into their operations to enhance the services they provide. The statement 'They are not referred to as proprietary organizations' is correct because proprietary organizations are typically for-profit entities, not non-profit ones.
4. Who typically owns a patient's medical record?
- A. The patient
- B. The physician
- C. The Legal Counsel of the Office
- D. No one owns a medical record
Correct answer: B
Rationale: The correct answer is 'The physician.' Physicians typically own their patients' medical records as they are the ones responsible for creating, updating, and maintaining these records. However, it is essential to note that patients have the legal right to access and obtain copies of their medical records. Choice A ('The patient') is incorrect as patients do not own their medical records, but they do have rights regarding access to them. Choice C ('The Legal Counsel of the Office') is incorrect as legal counsel typically do not own or have ownership rights over medical records. Choice D ('No one owns a medical record') is incorrect as medical records are owned by healthcare providers who create and maintain them, such as physicians.
5. A nurse is providing dismissal instructions for a child who was admitted for rotavirus. Which of the following statements by the parent indicates the need for further teaching?
- A. I'll start giving him his antibiotics as soon as we get home.
- B. I will call the physician if he becomes dizzy or overly fussy.
- C. He will need to wash his hands a lot to keep this from spreading.
- D. I'll watch to see when he stops having diarrhea stools.
Correct answer: A
Rationale: The correct answer is 'I'll start giving him his antibiotics as soon as we get home.' Rotavirus is a viral illness, and antibiotics are ineffective for its treatment. The parent's statement indicates a need for further teaching as antibiotics are not appropriate for treating rotavirus. Option B is correct as it demonstrates the parent's understanding of when to contact the physician for concerning symptoms. Option C is a correct statement regarding infection control practices. Option D is also correct as monitoring diarrhea stools is essential to track recovery from rotavirus.
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