NCLEX-RN
Saunders NCLEX RN Practice Questions
1. What is involved in obtaining informed consent?
- A. An explanation of the reasons for the procedure
- B. A signature on a form indicating the client agrees to the procedure
- C. A statement affirming liability if complications arise during the procedure
- D. Both A and C
Correct answer: A
Rationale: Informed consent involves providing the client with an explanation of the reasons for the procedure, the potential risks, benefits, and available alternatives. It is essential for the healthcare provider to ensure that the client understands the information provided before agreeing to the procedure. While obtaining a signature on a consent form is part of the process, it is not the sole indicator of informed consent. Option C, which mentions liability statements, is incorrect as informed consent focuses on ensuring the client understands the procedure, not on affirming liability. Therefore, the correct answer is the explanation of the reasons for the procedure.
2. Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for:
- A. Rest, Ice, Compression, Elevation
- B. Radiology, Ice, Compression, Elevation
- C. Rest, Ice, Cast, Elevation
- D. Radiology, Ice, Cast, Elevation
Correct answer: A
Rationale: The correct answer is Rest, Ice, Compression, Elevation. This acronym, RICE, is commonly used for the treatment of injuries like an ankle sprain. Rest allows the injured area to heal, Ice helps reduce swelling and pain (20 minutes on each hour while awake), Compression is usually achieved with an elastic bandage to minimize swelling, and Elevation of the foot above the level of the heart assists in reducing swelling and promoting healing. Choices B, C, and D are incorrect because they include irrelevant terms like Radiology and Cast, which are not part of the standard treatment protocol for an ankle sprain.
3. What is the expected date of delivery for your pregnant client when her last menstrual period was on 10/20/2016
- A. 7/7/2017
- B. 8/7/2017
- C. 6/7/2017
- D. 8/1/2017
Correct answer: A
Rationale: The expected date of delivery is calculated using Nagle's rule which is: The first day of last menstrual period - 3 months + 7 days = the estimated date of delivery
4. A client with a broken femur is in a traction splint in bed. Which of the following interventions is NOT part of caring for this client?
- A. Palpating the temperature of both feet
- B. Evaluating pulses bilaterally
- C. Turning the client to a side-lying position
- D. Relieving heel pressure by placing a pillow under the foot
Correct answer: C
Rationale: When caring for a client with a broken femur in a traction splint, turning the client to a side-lying position is not recommended. This client is at risk of skin breakdown and complications due to the injury, making it important to prevent unnecessary movement that may increase the risk of injury or discomfort. Palpating the temperature of both feet helps in assessing circulation, evaluating pulses bilaterally ensures perfusion to the extremities, and relieving heel pressure by placing a pillow under the foot helps in reducing pressure points and preventing complications like pressure ulcers. Therefore, the correct answer is turning the client to a side-lying position as it is not a recommended intervention in this scenario.
5. Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.
- A. ask for assistance before getting out of bed.
- B. remain in bed because it is safer and he will not fall.
- C. instruct him to stand up quickly from the bed.
- D. lean forward and push up and off the bed.
Correct answer: A
Rationale: The nurse should encourage Mr. Freeman to use his call bell and ask for assistance before getting out of bed. This can prevent him from falling. Patients should not stay in bed; they should be encouraged to get out of bed as much as possible to prevent complications like pressure ulcers and muscle weakness. Instructing a patient to stand up quickly from the bed is unsafe as it can lead to dizziness and falls. Similarly, leaning forward and pushing off the bed can increase the risk of falls and should be avoided. Asking for assistance is the safest and most appropriate option to ensure patient safety and prevent accidents.
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