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. Which of the following is an example of restorative care?
- A. A nurse teaches a new mother how to breastfeed her infant
- B. A nurse helps a client with developing a bladder-retraining program
- C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
- D. A nurse contacts the family of a client to tell them he will be out of surgery soon
Correct answer: B
Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.
3. A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?
- A. G4 T1 P0 A1 L2
- B. G3 T1 P0 A1 L2
- C. G3 T0 P1 A1 L2
- D. G4 T0 P1 A1 L2
Correct answer: D
Rationale: The correct answer is G4 T1 P0 A1 L2. This documentation accurately represents the woman's obstetric history. G4: She is currently pregnant (1), has twins (1), and had a miscarriage (1), totaling four pregnancies. T1: She has had one pregnancy that resulted in the birth of her twins at term. P0: She has not had any preterm births. A1: She had one miscarriage at 12 weeks gestation. L2: She has two living children (the twins). Therefore, the correct documentation reflects all aspects of her obstetric history as provided.
4. A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam?
- A. Start the hepatitis B immunization series.
- B. Teach the patient about hepatitis A immune globulin.
- C. Ask whether the patient has been screened for hepatitis C.
- D. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).
Correct answer: C
Rationale: The correct action for the nurse to include in care when the patient is seen for a routine annual physical exam, according to CDC guidelines, is to ask whether the patient has been screened for hepatitis C. CDC guidelines recommend screening patients born between 1945 and 1965 for hepatitis C due to the high prevalence of undiagnosed cases in this age group. Starting the hepatitis B immunization series is not necessary as the patient already had hepatitis A infection. Teaching the patient about hepatitis A immune globulin is not indicated in this scenario. Testing for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM) is not needed as the patient has already had hepatitis A.
5. Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?
- A. A 65-year old male with urine output of 60cc in the past four hours
- B. A 2-month old female with a temperature of 100.6 rectally
- C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
- D. A 4-year old male with an oxygen saturation of 96% on room air
Correct answer: D
Rationale: Clients must meet a certain amount of set criteria before they will be discharged from a healthcare facility. Although guidelines may vary between locations, most healthcare facilities expect clients to have adequate oxygenation, nutrition, and elimination; and be free from fever, vomiting, and significant pain
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