NCLEX-RN
Saunders NCLEX RN Practice Questions
1. At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?
- A. A 91-year-old man who needs help eating breakfast
- B. An 86-year-old man who has been incontinent in his bed
- C. An 82-year-old woman who needs IV antibiotics
- D. A 75-year-old man who is recovering from an injury and needs an ice pack
Correct answer: C
Rationale: When prioritizing care in a long-term care facility, the nurse must consider tasks that require their immediate attention and cannot be delegated. Administering IV antibiotics is a critical nursing task that only the nurse can perform, ensuring the timely and correct delivery of medication to the patient. While assisting with breakfast, managing incontinence, and providing an ice pack are important, these tasks can be delegated to other healthcare team members, allowing the nurse to address the client needing IV antibiotics first to ensure effective treatment and patient safety.
2. 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?
- A. Call the supervisor and file a complaint against the physical therapy department
- B. Contact the physician to notify him that the orders were not carried out
- C. Assess the client's activity level by assisting with ambulation using a gait belt
- D. Contact the physical therapy department again and repeat the order
Correct answer: D
Rationale: In this situation, the most appropriate action for the nurse to take is to contact the physical therapy department again and repeat the order. It is crucial to ensure that the client receives the necessary care as prescribed. Following up with the department reinforces the importance of the order and increases the likelihood of prompt action. Option A is incorrect because escalating the situation to filing a complaint should be a last resort after all other communication attempts have failed. Option B is not the best course of action as the first step should be to ensure proper communication within the healthcare team. Option C is not the priority in this scenario, as the immediate concern is to address the delay in the physical therapy consult.
3. Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?
- A. Collect and organize documents for the client's medical record
- B. Prepare the client's identification bracelet
- C. Identify pertinent health history data and current needs and limitations
- D. Gather the client's valuables and secure them in a locked container
Correct answer: C
Rationale: When a client is admitted to a stroke care unit in a rehabilitation center, the nurse's initial priority is to assess the client. This assessment includes identifying relevant health history data that may impact the client's care. By recognizing the client's current needs and limitations, the nurse can develop a comprehensive understanding of the client's condition. This information is crucial for generating a nursing diagnosis and establishing appropriate care outcomes. While collecting and organizing documents for the medical record, preparing identification bracelets, and securing valuables are important tasks, they are not the primary actions that directly influence the client's immediate care upon admission.
4. A nursing unit is implementing a new electronic charting program for the nursing staff to use. Which of the following best describes a disadvantage of using electronic charting?
- A. The information is more likely to be lost or used inappropriately.
- B. Any provider in the unit can have access to the client's medical records.
- C. The system diminishes communication between nurses and providers.
- D. The program may be confusing and difficult to implement.
Correct answer: D
Rationale: A significant disadvantage of implementing a new electronic charting program is the potential for complexity and difficulty in implementation. Introducing a new system requires time and education for staff to adapt and use it appropriately. Users may experience confusion as they learn to navigate the new charting techniques, which can impact workflow efficiency and accuracy. Option A is incorrect because electronic charting systems are designed to enhance data security and integrity, reducing the risk of information being lost or misused. Option B is incorrect as access control mechanisms can restrict who can view specific patient records. Option C is incorrect as electronic charting systems often facilitate communication between healthcare providers by providing real-time access to patient information.
5. What does the 'B' in the SBAR acronym stand for?
- A. Background
- B. Basic
- C. Beginning
- D. Break
Correct answer: A
Rationale: The 'B' in the SBAR acronym stands for Background. SBAR is a standardized communication tool used in healthcare to effectively communicate critical information. In this context, 'Background' refers to providing relevant information about the patient's history, current status, and any other pertinent details. This information helps ensure clear and concise communication between healthcare providers, enhancing patient care. Choice B, 'Basic,' is incorrect as the 'B' specifically emphasizes the detailed background information. Choices C and D, 'Beginning' and 'Break,' are not accurate in the context of the SBAR communication tool.
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