NCLEX NCLEX-RN
Saunders NCLEX RN Practice Questions
1. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?
- A. The approximate length of the surgery
- B. The type of anticoagulants that will be prescribed
- C. The time of the next meal of solid food
- D. The length of time until the client can return to work
Correct answer: The approximate length of the surgery
Rationale: The priority topic to instruct a client admitted for a total knee replacement surgery should be the approximate length of the surgery. Pre-surgical teaching should focus on preparing the client for the upcoming procedure. Providing information about the duration of the surgery can help manage the client's expectations, reduce anxiety, and ensure they are mentally prepared for the operation. While details about post-operative care, anticoagulants, meals, and return to work are important, they are not the immediate priority during the preoperative phase. These aspects can be addressed at a later stage in the client's care journey.
2. A client presents with symptoms of a sore throat, swollen lymph nodes in the neck, fever, chills, and extreme fatigue. Based on these symptoms, which of the following illnesses could the nurse consider for this client?
- A. Methicillin-resistant Staphylococcus aureus (MRSA)
- B. Hepatitis B
- C. Infectious mononucleosis
- D. Norovirus infection
Correct answer: Infectious mononucleosis
Rationale: Infectious mononucleosis is a viral disease caused by the Epstein-Barr virus. The symptoms of sore throat, fever, chills, swollen lymph nodes, and extreme fatigue are characteristic of infectious mononucleosis. The diagnosis is confirmed through the client's history and blood tests for the Epstein-Barr virus. Methicillin-resistant Staphylococcus aureus (MRSA) presents with localized skin infections, not the systemic symptoms described. Hepatitis B typically presents with jaundice, abdominal pain, and liver inflammation, not the symptoms described. Norovirus infection commonly causes gastrointestinal symptoms like vomiting and diarrhea, not the symptoms presented by the client.
3. While suctioning the endotracheal tube of an adult client, what level of pressure should the nurse apply?
- A. 70-80 mmHg
- B. 100-120 mmHg
- C. 150-170 mmHg
- D. 200 mmHg
Correct answer: 100-120 mmHg
Rationale: When suctioning the endotracheal tube of an adult client, the nurse should set the suction apparatus at a level no higher than 150 mmHg, with a preferable level between 100 and 120 mmHg. Suction pressure that is too high can contribute to the client's hypoxia. Alternatively, too low suction pressure may not clear adequate amounts of secretions. Choice A (70-80 mmHg) is too low and may not effectively clear secretions. Choices C (150-170 mmHg) and D (200 mmHg) are too high and can potentially harm the client by causing hypoxia or damaging the airway.
4. The nurse is preparing to examine a 4-year-old child. Which action by the nurse is appropriate for this age group?
- A. Explain the procedures briefly to alleviate the child’s anxiety.
- B. Give the child feedback and reassurance during the examination.
- C. Ask the child to undress as needed for the examination.
- D. Perform an examination of the head last.
Correct answer: Give the child feedback and reassurance during the examination.
Rationale: For a 4-year-old child, short and simple explanations should be provided to avoid overwhelming the child. It is important to give feedback and reassurance during the examination to create a comforting environment for the child. Asking the child to undress as needed is appropriate for a thorough examination, as children at this age are usually willing to do so. Performing an examination of the head last allows the child to become more comfortable during the assessment. Therefore, the most appropriate action for a 4-year-old child is to provide feedback and reassurance during the examination, ensuring a positive experience for the child.
5. The discharge planning team is discussing plans for the dismissal of a 16-year-old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning processes but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?
- A. The client is an emancipated minor
- B. The mother has to work and is unavailable
- C. The client has a job and a driver's license
- D. The mother does not speak English
Correct answer: The client is an emancipated minor
Rationale: In this scenario, the correct answer is that the client is an emancipated minor. Emancipated minors, even if they are under the age of 18, have the legal right to make decisions about their own healthcare and planning, which may include not wanting their parent involved in the discharge planning process. This status grants them independence from parental involvement in certain situations. The other choices are incorrect because the mother's work schedule, the client's job and possession of a driver's license, and the mother's language proficiency do not inherently prevent her from participating in the discharge planning process, unlike the legal status of being an emancipated minor.
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