NCLEX-RN
Saunders NCLEX RN Practice Questions
1. Which of the following is an example of low health literacy skills?
- A. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
- B. A client cannot read an admission form to sign it
- C. A nurse cannot calculate the correct IV rate for Ringer's lactate
- D. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
Correct answer: B
Rationale: Low health literacy skills are exemplified by an individual's inability to comprehend health-related information. In this scenario, a client's inability to read an admission form to sign it indicates low health literacy. This lack of understanding can hinder their ability to make informed decisions about their healthcare. The other choices involve healthcare professionals and their knowledge or skills, not the health literacy of individuals seeking care.
2. Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?
- A. Air embolism.
- B. Cerebral hemorrhage.
- C. Expansion of the clot.
- D. Resolution of the clot.
Correct answer: B
Rationale: Cerebral hemorrhage is a significant complication associated with thrombolytic therapy in stroke treatment. Thrombolytic therapy aims to dissolve clots, but it increases the risk of bleeding, including cerebral hemorrhage. This risk is especially high when the therapy is administered quickly after a stroke, sometimes before confirming the type of stroke. Air embolism (Choice A) is not a common complication of thrombolytic therapy. Expansion of the clot (Choice C) and resolution of the clot (Choice D) are not expected outcomes of thrombolytic therapy; the therapy is specifically used to dissolve clots, not to expand or resolve them.
3. A systemic sign of infection is ______________.
- A. swelling
- B. redness
- C. heat
- D. a lack of appetite
Correct answer: D
Rationale: The correct answer is 'a lack of appetite.' When a person experiences a systemic infection, they may exhibit signs that affect the entire body. A lack of appetite is a common systemic sign of infection, along with other symptoms like rapid pulse, fever, and an elevated white blood cell count. Swelling, redness, and heat are more indicative of localized inflammation or infection, rather than systemic involvement.
4. In a clinic in a primarily African American community, a higher incidence of uncontrolled hypertension is noted in patients. To correct this health disparity, what should the nurse do first?
- A. Initiate a regular home-visit program by clinic nurses.
- B. Schedule teaching sessions about low-salt diets at community events.
- C. Assess the perceptions of community members about the care at the clinic.
- D. Obtain low-cost antihypertensive drugs using government grant funding.
Correct answer: C
Rationale: To address the higher incidence of uncontrolled hypertension in the primarily African American community, the nurse should first assess the perceptions of community members about the care at the clinic. Understanding the community's perspective can provide valuable insights into the reasons behind the health disparity. Initiating a regular home-visit program or scheduling teaching sessions about low-salt diets are important interventions but should come after gathering information on community perceptions. Obtaining low-cost antihypertensive drugs is not the initial priority; understanding community perspectives is crucial for developing effective interventions.
5. 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.
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