NCLEX-RN
Saunders NCLEX RN Practice Questions
1. A nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:
- A. Psychological abuse
- B. Abandonment
- C. Material exploitation
- D. Physical abuse
Correct answer: A
Rationale: The correct answer is A: Psychological abuse. This behavior is classified as psychological abuse, which harms another person through words or threats. The nursing assistant's actions of yelling, making threats, and using food as a form of control fall under psychological abuse. Abandonment (choice B) refers to deserting or leaving a client without care, which is not the case in the scenario. Material exploitation (choice C) involves taking advantage of a person's assets or resources for personal gain, which is not evident here. Physical abuse (choice D) involves causing physical harm, which is not the primary issue in this situation. Therefore, the most appropriate classification for the behavior described in the scenario is psychological abuse.
2. Which action represents the evaluation stage of the plan of care?
- A. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation
- B. The nurse assesses the client's vital signs and asks about symptoms
- C. The nurse determines that the client is not meeting his set outcomes and makes revisions
- D. The nurse discusses the client's health history
Correct answer: C
Rationale: The correct answer is C. The evaluation stage of the nursing process involves reviewing the assessments, diagnoses, and interventions given to the client and then determining if the client is meeting expected outcomes. In this scenario, the nurse is assessing whether the client is meeting the outcomes set for their care plan and making revisions as needed. Choice A is incorrect as assigning a nursing diagnosis is part of the nursing diagnosis phase, not the evaluation phase. Choice B represents the assessment phase of the nursing process, not the evaluation phase. Choice D involves discussing the client's health history, which is more aligned with the assessment phase rather than the evaluation phase.
3. A client is admitted to a nursing unit with a remittent fever. Which statement best describes this pattern of fever?
- A. A fever that spikes and then lowers without returning to normal
- B. A fever that lasts 2 days followed by normal temperature for 2 days, followed by fever again
- C. A fever that lasts 2 days followed by normal temperature for 12 hours, followed by fever again
- D. A persistent fever that has lasted over 24 hours
Correct answer: A
Rationale: A remittent fever is characterized by temperature fluctuations where the fever spikes and then lowers but does not return to normal temperature. Option A best describes this pattern of fever. Option B describes a pattern of fever known as a biphasic fever, where the fever alternates between days of fever and normal temperature. Option C describes a pattern of fever that is more indicative of an intermittent fever, where the fever lasts for a specific duration followed by an interval of normal temperature. Option D does not accurately describe a remittent fever, as it suggests a persistent fever that has lasted over 24 hours, which is not specific to the remittent pattern.
4. Which of the following is a true statement about assessing blood pressure by palpation?
- A. Only the diastolic blood pressure can be assessed through palpation.
- B. The palpation technique is most useful for infants and small children.
- C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
- D. Only the systolic blood pressure can be assessed through palpation.
Correct answer: D
Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.
5. Because of budget cuts in the hospital, the nursing manager informs the staff that they must either rotate to other units more often or take their turns staying home from work. Which principle is this nurse manager demonstrating?
- A. Justice
- B. Paternalism
- C. Veracity
- D. Fraternity
Correct answer: D
Rationale: Veracity involves truth-telling, even in challenging situations. In this scenario, the nurse manager is being transparent about the need for staff to rotate units or take turns staying home due to budget cuts. This allows the staff to make informed decisions about their work schedules and potential impact on their pay and work areas. Option A, Justice, does not apply as the focus is on communication and transparency, not fairness. Option B, Paternalism, does not fit as it involves decisions made for others' well-being without their input, which is not the case here. Option D, Fraternity, pertains to unity among individuals, which is not the principle demonstrated by the nurse manager in this situation.
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