NCLEX NCLEX-RN
Saunders NCLEX RN Practice Questions
1. Which of the following is an example of whistle-blowing?
- A. A nurse contacts administration about a colleague who takes supplies to use for a mission trip
- B. A client sues a nurse because she failed to call the physician about his wound infection
- C. A nursing assistant calls for help when a client falls out of bed
- D. A client developed a sacral pressure ulcer when he was not turned in bed for over four hours
Correct answer: A nurse contacts administration about a colleague who takes supplies to use for a mission trip
Rationale: Whistle-blowing involves notifying administration or a supervisor about unethical or illegal activities. In this scenario, the nurse reporting a colleague taking supplies for personal use is an example of whistle-blowing as it involves reporting behavior that is dishonest and potentially harmful. Choices B, C, and D do not represent whistle-blowing. Choice B involves a legal action by a client against a nurse, choice C is a situation where immediate care is provided, and choice D is a case of neglect that should have been prevented.
2. Which of the following nursing interventions is appropriate for a client suffering from a fever?
- A. Avoid withholding food from the client
- B. Increase the client's fluid intake
- C. Provide oxygen
- D. All answers are correct
Correct answer: Increase the client's fluid intake
Rationale: The appropriate nursing intervention for a client suffering from a fever is to increase the client's fluid intake. A fever can elevate the body's metabolism, leading to increased breathing and heart workload. This can result in fluid loss due to heightened respiration and sweating. Moreover, the augmented heart workload may necessitate more oxygen to maintain tissue perfusion. Providing oxygen and increasing fluid intake help meet the body's heightened demands during a fever. Withholding food from the client is inappropriate as proper nutrition is crucial for recovery, and providing oxygen alone may not address the fluid and metabolic demands associated with fever. Therefore, the correct choice is to increase the client's fluid intake.
3. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to
- A. choose low-fat foods from the menu
- B. perform leg exercises hourly while awake
- C. ambulate the evening of the operative day
- D. turn, cough, and deep breathe every 2 hours
Correct answer: turn, cough, and deep breathe every 2 hours
Rationale: Postoperative nursing care after a cholecystectomy focuses on preventing respiratory complications due to the surgical incision being high in the abdomen, which impairs coughing and deep breathing. Turning, coughing, and deep breathing every 2 hours help prevent respiratory complications, such as pneumonia. While choices A, B, and C are also important aspects of postoperative care, they are not as high a priority as ensuring proper ventilation and respiratory function in the immediate postoperative period.
4. Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?
- A. Maintain a constant connection to low-intermittent suction
- B. Irrigate the tube as per physician's order
- C. Suction the mouth and nose every shift
- D. Perform a daily fecal occult blood sample
Correct answer: Irrigate the tube as per physician's order
Rationale: The correct answer is to irrigate the tube as per physician's order. A client with a nasogastric tube is at risk of the tube kinking or clotting off, which can lead to complications such as abdominal distention or vomiting. To ensure the patency of the tube, the nurse should follow the physician's orders and facility policy to irrigate the tube with water or a solution as needed. Maintaining a constant connection to low-intermittent suction (Choice A) is not typically done to maintain tube patency. Suctioning the mouth and nose every shift (Choice C) is not directly related to maintaining nasogastric tube patency. Performing a daily fecal occult blood sample (Choice D) is unrelated to maintaining the patency of a nasogastric tube.
5. A nurse is caring for an infant who has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
- A. Slow pulse rate
- B. Weight gain
- C. Decreased systolic pressure
- D. Irregular WBC lab values
Correct answer: Weight gain
Rationale: Weight gain due to fluid accumulation is associated with heart failure and congenital heart defects. When the heart is unable to circulate blood normally, the kidneys receive less blood, leading to reduced fluid filtration into the urine. The excess fluid accumulates in various body parts such as the lungs, liver, eyes, and sometimes in the legs. Slow pulse rate (Choice A) is less likely as infants with heart failure typically present with tachycardia due to the body compensating for decreased cardiac output. Decreased systolic pressure (Choice C) is also less likely as heart failure typically leads to increased blood pressure as the body tries to maintain adequate perfusion. Irregular white blood cell (WBC) values (Choice D) are not directly associated with congenital heart defects unless there is an underlying infection or inflammatory process.
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