NCLEX-RN
Saunders NCLEX RN Practice Questions
1. The discharge planning team is discussing plans for the dismissal of a 16-year-old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning processes but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?
- A. The client is an emancipated minor
- B. The mother has to work and is unavailable
- C. The client has a job and a driver's license
- D. The mother does not speak English
Correct answer: A
Rationale: In this scenario, the correct answer is that the client is an emancipated minor. Emancipated minors, even if they are under the age of 18, have the legal right to make decisions about their own healthcare and planning, which may include not wanting their parent involved in the discharge planning process. This status grants them independence from parental involvement in certain situations. The other choices are incorrect because the mother's work schedule, the client's job and possession of a driver's license, and the mother's language proficiency do not inherently prevent her from participating in the discharge planning process, unlike the legal status of being an emancipated minor.
2. A teacher brings a 5-year-old child to the school nurse because of a bruise under her eye. When asked about the bruise, the child responds, 'my daddy did it.' What is the nurse's initial action in this situation?
- A. Allow the child to return to class and monitor for future events that are suggestive of abuse
- B. Call the parent and request an explanation for the bruises
- C. Call the police and ask for a warrant for the parent's arrest
- D. Notify the school administrator
Correct answer: D
Rationale: In cases of suspected child abuse, the priority for the school nurse is to notify the school administrator immediately. The school administrator can then collaborate with the nurse to follow established protocols for reporting suspected abuse to the appropriate authorities. All suspicions or allegations of child abuse must be handled with sensitivity and in compliance with state laws and school policies. All other options, such as allowing the child to return to class without further action, directly contacting the parent, or involving the police without proper investigation, could potentially compromise the safety and well-being of the child and may not adhere to legal requirements for reporting suspected abuse.
3. 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.
4. Albert B. is incontinent of urine. He also wears glasses and hearing aids. His ____________lead(s) to his risk for falls.
- A. incontinence and loss of vision
- B. loss of vision
- C. incontinence
- D. loss of hearing
Correct answer: B
Rationale: Albert B. is at risk for falls due to two factors: his incontinence and his loss of vision. Loss of vision significantly impairs one's ability to navigate and avoid obstacles, thereby increasing the risk of falls. While incontinence is a risk factor for falls, the primary concern in this case is the loss of vision since it directly affects balance and safety. Therefore, the correct answer is 'loss of vision.' Choices A, C, and D are incorrect because they do not address the key factor of impaired vision leading to the risk of falls.
5. 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.
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