a student is late for their appointment and has rushed across campus to the health clinic how would the nurse proceed
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Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?

Correct answer: A

Rationale: To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.

2. Which acronym would BEST describe the procedure for assessing a patient that appears unconscious?

Correct answer: D

Rationale: The correct answer is D, 'ABC.' The ABC method stands for Airway, Breathing, Circulation. When encountering an unconscious patient, it is crucial to first ensure their Airway is clear by performing the 'head tilt, chin lift' maneuver. Next, assess Breathing by observing for chest rise and fall, listening for breath sounds, and feeling for airflow. Finally, check for Circulation by assessing for a pulse. Choices A, B, and C ('WBC,' 'QRS,' 'XYZ') are incorrect as they do not represent the standard approach to assessing an unconscious patient.

3. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

Correct answer: C

Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.

4. Which of the following is an example of physical abuse?

Correct answer: A

Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.

5. What would be an appropriate evaluation statement for the nurse to write based on the client's ability to state only two signs of impaired circulation out of three as expected?

Correct answer: C

Rationale: The appropriate evaluation statement for the nurse to write would be 'Goal not met: Client able to name only two signs of impaired circulation.' In this scenario, the client has only identified two out of the three signs of impaired circulation specified in the desired outcome. Therefore, the goal has not been fully achieved. It is essential in nursing practice to assess and document client progress accurately. While the client has shown some understanding by correctly identifying numbness and tingling as signs of impaired circulation, the inability to state the third sign indicates an incomplete achievement of the goal. This evaluation helps guide further interventions or educational strategies to help the client meet the desired outcome in the care plan.

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