NCLEX-RN
Saunders NCLEX RN Practice Questions
1. A nurse is using active listening as a form of therapeutic communication when:
- A. She uses humor to put the client at ease in a situation
- B. She restates what the client said in slightly different words
- C. She uses eye contact and maintains an open stance while the client is talking
- D. She provides personal information to show the client she can relate to him
Correct answer: C
Rationale: Active listening is a form of therapeutic communication that involves the nurse encouraging a client to express their thoughts and feelings. Maintaining eye contact and an open stance while the client is talking demonstrates active listening and shows the client that they are being heard and understood. Using humor (Choice A) may not always be appropriate or therapeutic in all situations. Restating what the client said (Choice B) is a technique known as paraphrasing and is also a form of active listening. Providing personal information (Choice D) can shift the focus from the client to the nurse, which is not the intention of active listening.
2. You are on the unit and overhear another nurse talking on the phone to a patient's friend who wants to see her patient who is comatose and on a ventilator. Since you cared for that patient yesterday, you know that the patient's significant other, who is also the designated healthcare surrogate (HCS) and has power of attorney (POA), has expressly stated that he wants this person on the list for restricted visitors. The nurse whispers that she'll call him to visit as soon as the significant other has gone home. What should your first response be?
- A. Inform the significant other
- B. Report the nurse to the nurse manager
- C. Speak with the nurse directly in private
- D. Call the visitor and tell him he can't visit
Correct answer: C
Rationale: Speaking with the nurse directly and privately is the most constructive manner in which to handle this situation and advocate for the significant other's wishes. Doing so will open communication with a peer and build the relationship, instead of alienating the other nurse by taking action that does not involve her and will cast her in a negative light with others. It is essential to express your concerns regarding honoring the significant other's requests and rights regarding the limitation of visitors. Option A is incorrect because the significant other is not the one trying to visit, and it is more appropriate to address the nurse directly first. Option B is not the best initial response as it may escalate the situation without giving the nurse a chance to correct the issue. Option D is incorrect as it does not address the issue at its source and may create further conflict without resolving the underlying problem.
3. A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?
- A. Myocardial infarction due to a history of atherosclerosis.
- B. Pulmonary embolism due to deep vein thrombosis (DVT).
- C. Anxiety attacks due to worries about her baby's health.
- D. Congestive heart failure due to fluid overload.
Correct answer: B
Rationale: In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs, known as deep vein thrombosis (DVT). These clots can dislodge and travel to the lungs, causing a pulmonary embolism. Myocardial infarction (Choice A) is less likely in a young patient without a significant history of atherosclerosis. Anxiety attacks (Choice C) may present with similar symptoms but are less likely in this context. Congestive heart failure (Choice D) is less probable given the acute onset of symptoms and absence of typical signs like peripheral edema in this case.
4. You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT:
- A. PT referral for development of a planned exercise program
- B. Avoidance of prolonged sun exposure
- C. Hot baths to promote muscle relaxation
- D. Instructions to evaluate the home environment to ensure safety
Correct answer: C
Rationale: Discharge instructions for a patient with newly diagnosed multiple sclerosis should focus on promoting safety and minimizing exacerbations. Hot baths should be avoided as excessive heat can trigger acute symptoms. Therefore, instructions may include PT referral for an exercise program to maintain mobility, avoidance of prolonged sun exposure to prevent symptom exacerbation, and guidance to evaluate the home environment for safety as symptoms progress. Hot baths are not recommended due to the risk of exacerbating symptoms, making it the correct answer. Choices A, B, and D are appropriate for a patient with multiple sclerosis, as they address mobility, symptom management, and safety concerns, respectively.
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.
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