NCLEX-RN
Saunders NCLEX RN Practice Questions
1. Examples of preservation of self-integrity include all of the following except:
- A. Using assistive equipment to move bariatric clients
- B. Participating in wellness programs
- C. Accepting the challenge of caring for clients with oppositional beliefs or practices
- D. Using hand hygiene and personal protective equipment
Correct answer: C
Rationale: Preservation of self-integrity involves actions that support the nurse's well-being and ethical standards. Using assistive equipment to move bariatric clients and practicing hand hygiene and personal protective equipment are essential aspects of maintaining physical health and safety, contributing to self-care. Participating in wellness programs further enhances self-care by promoting overall well-being. However, accepting the challenge of caring for clients with oppositional beliefs or practices can be emotionally taxing and may compromise a nurse's self-integrity if it leads to significant moral distress or ethical conflicts. In such situations, it is important for nurses to prioritize their well-being and ethical values by seeking alternative solutions or support.
2. Which of the following clients have barriers to accessing healthcare?
- A. A 36-year-old client who must use a wheelchair for mobility
- B. A 44-year-old client who is visiting the United States on a visa from India
- C. An 81-year-old client who is unable to drive
- D. All of the above
Correct answer: D
Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments. Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.
3. A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
- A. External light sources may cause falsely high oximetry values
- B. A bright light in the client's face may cause a low pulse oximetry
- C. External light sources may cause falsely low oximetry values
- D. The client needs a dark and quiet room to recover and maintain proper oxygenation
Correct answer: A
Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.
4. 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.
5. 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.
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