NCLEX-RN
Saunders NCLEX RN Practice Questions
1. A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?
- A. Contact the state board of nursing licensure to report the offense
- B. Review the state scope of practice standards for nurses
- C. Ask another nurse to perform the task to learn the procedure
- D. Contact the house supervisor to make the decision on whether the nurse should perform the task
Correct answer: B
Rationale: When faced with a task that a nurse believes may be beyond their scope of practice, it is essential to refer to the state's specific scope of practice standards for nurses. This step is crucial as these standards can vary between states, providing clarity on what tasks are permissible. By reviewing these standards, the nurse can determine if the task falls within their scope of practice. Contacting the state board of nursing licensure to report the offense (Choice A) is premature and should only be considered if there is a serious violation after reviewing the scope of practice. Asking another nurse to perform the task (Choice C) does not address the issue of clarifying the scope of practice. Contacting the house supervisor (Choice D) may be necessary if the nurse cannot determine the appropriateness of the task based on the scope of practice standards.
2. The BRAT diet is often prescribed for patients with gastroenteritis. This acronym stands for:
- A. Bananas, Rice, Applesauce, and Toast
- B. Bread, Rice, Apricots, and Tapioca
- C. Bananas, Rolls, Apricots, and Toast
- D. Bananas, Rolls, Applesauce, and Tapioca
Correct answer: A
Rationale: The BRAT diet, which stands for Bananas, Rice, Applesauce, and Toast, is commonly recommended for patients with gastroenteritis. These easily digestible foods help firm up stools due to their low fiber content and provide essential nutrients lost during vomiting and diarrhea. Choice B is incorrect because it includes apricots, which are not part of the traditional BRAT diet. Choice C is incorrect as it includes rolls, which are not typically included in the BRAT diet. Choice D is incorrect as it includes tapioca, which is not part of the traditional BRAT diet. Therefore, the correct answer is Bananas, Rice, Applesauce, and Toast.
3. Plantar flexion can be prevented with ________________.
- A. foot soaks
- B. foot boards
- C. toenail care
- D. proper shoes
Correct answer: B
Rationale: Plantar flexion, or foot drop, can be prevented with foot boards, special splints, and range of motion exercises. Foot boards help maintain the foot in a neutral position, preventing contractures and deformities. Foot soaks (choice A) may help with foot hygiene but do not directly prevent plantar flexion. Toenail care (choice C) is important for overall foot health but does not prevent plantar flexion. Proper shoes (choice D) are essential for foot support and comfort but do not specifically prevent plantar flexion.
4. Which of the following is a true statement about assessing blood pressure by palpation?
- A. Only the diastolic blood pressure can be assessed through palpation.
- B. The palpation technique is most useful for infants and small children.
- C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
- D. Only the systolic blood pressure can be assessed through palpation.
Correct answer: D
Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.
5. Which of the following is an example of a breach of a client's right to privacy?
- A. A nurse who is not caring for the client reads the client's personal information in the chart
- B. A client is not allowed to keep a copy of their original medical record
- C. A nurse files an incident report about a client that is reviewed with all staff at a meeting
- D. A client's photograph is used without permission for the hospital newsletter
Correct answer: D
Rationale: A breach of a client's right to privacy can occur when their personal information is used or disclosed without their consent. In this scenario, using a client's photograph without permission for the hospital newsletter violates their privacy rights. It is important to respect a client's confidentiality and seek their consent before using their personal information. Choices A, B, and C do not directly relate to breaching a client's right to privacy. Reading a client's personal information in their chart, not allowing a client to keep a copy of their medical record, and filing an incident report about a client do not necessarily violate their privacy rights as long as the information is handled appropriately and within legal and ethical boundaries.
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