a nurse in the emergency room enters a clients care area to start an iv she finds a man sitting on the table hunched over and attempting to take deep

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. What would a healthcare professional expect to observe while assessing the growth of children during their school-age years?

A. Decreasing amounts of body fat and muscle mass
B. Little change in body appearance from year to year
C. Progressive height increase of 4 inches each year
D. Yearly weight gain of about 5.5 pounds per year

Correct answer: D

Rationale: During school-age years, children typically gain about 5.5 pounds per year and increase in height by about 2 inches annually. This steady growth pattern is expected between ages 2 to 10 years. Choice A is incorrect as children at this stage are expected to gain weight and grow in height. Choice B is incorrect as there should be noticeable changes in body appearance due to growth. Choice C is incorrect as a progressive height increase of 4 inches each year is not typical during the school-age years.

3. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?

A. The approximate length of the surgery
B. The type of anticoagulants that will be prescribed
C. The time of the next meal of solid food
D. The length of time until the client can return to work

Correct answer: A

Rationale: The priority topic to instruct a client admitted for a total knee replacement surgery should be the approximate length of the surgery. Pre-surgical teaching should focus on preparing the client for the upcoming procedure. Providing information about the duration of the surgery can help manage the client's expectations, reduce anxiety, and ensure they are mentally prepared for the operation. While details about post-operative care, anticoagulants, meals, and return to work are important, they are not the immediate priority during the preoperative phase. These aspects can be addressed at a later stage in the client's care journey.

4. Your patient has been diagnosed with herpes simplex virus 2. Which of the following would NOT be included in your teaching of this patient?

A. If you have symptoms, you should avoid sexual contact with other individuals.
B. With treatment, this condition can be cured.
C. This disease is highly contagious.
D. You may experience tingling in the skin before an active outbreak occurs.

Correct answer: B

Rationale: The correct answer is 'With treatment, this condition can be cured.' The treatment for herpes simplex virus (HSV) is symptomatic and palliative, aimed at managing symptoms rather than curing the infection. HSV is highly contagious, so sexual contact should be avoided during active outbreaks to prevent transmission. Many patients experience a tingling sensation in the skin before an active outbreak, known as a prodrome. Educating the patient that the condition is not curable but manageable with treatment is vital to set realistic expectations and promote proper management of the disease.

5. Which of the following is an example of intragroup conflict?

A. A nurse writes a grant for a non-profit organization to raise money for advertising
B. Members of a multidisciplinary team cannot agree on the best course of action for a client
C. A client does not receive his medication on time because the nurse was on break
D. A nurse feels frustrated that her employer does not provide on-site child care

Correct answer: B

Rationale: Intragroup conflict refers to disagreements within a group. The correct answer, 'Members of a multidisciplinary team cannot agree on the best course of action for a client,' exemplifies this type of conflict well. In this scenario, professionals within the same team are unable to reach a consensus on how to proceed with client care. Choices A, C, and D do not reflect intragroup conflict. Writing a grant for a non-profit organization, a client not receiving medication due to a nurse's break, and a nurse feeling frustrated about the lack of on-site child care do not involve conflicts within a group of professionals.