NCLEX NCLEX-RN
Saunders NCLEX RN Practice Questions
1. Which example best describes the concept of beneficence?
- A. A nurse provides pain medication for a client in the recovery room who is experiencing pain
- B. A client has an advanced directive in place stating that he does not want intubation if he needs CPR
- C. At the request of the client, a nurse does not inform the family about his cancer diagnosis
- D. A nurse withholds narcotic medication for a client in pain, knowing that he is currently disoriented
Correct answer: A nurse provides pain medication for a client in the recovery room who is experiencing pain
Rationale: Beneficence is the ethical principle of doing good and acting in the best interest of the client. Providing pain relief to a client in the recovery room who is experiencing pain aligns with beneficence as it promotes the client's well-being and comfort. Choice B is related to autonomy, where the client's wishes regarding treatment are respected. Choice C involves confidentiality and the client's right to privacy. Choice D represents nonmaleficence, as withholding pain medication from a client in pain could cause harm and goes against the principle of doing no harm.
2. Your patient had a stroke, or CVA, five years ago. The resident still has right-sided weakness. You are ready to transfer the resident from the bed to the wheelchair. The wheelchair should be positioned at the _____________.
- A. head of the bed on the patient's right side
- B. head of the bed on the patient's left side
- C. bottom of the bed on the patient's right side
- D. bottom of the bed on the patient's left side
Correct answer: head of the bed on the patient's left side
Rationale: The wheelchair should be positioned at the head of the bed on the resident's left side. This positioning allows the resident to use their stronger left side to assist with the transfer, compensating for the right-sided weakness. Placing the wheelchair at the head of the bed on the patient's right side (Choice A) would not utilize the stronger left side, which is crucial for the transfer. Similarly, positioning the wheelchair at the bottom of the bed on either side (Choices C and D) would not facilitate optimal assistance from the resident's stronger side during the transfer process.
3. During a discussion about glaucoma at the community center, which comment by one of the retirees would the nurse give a supportive comment to reinforce correct information?
- A. ''I usually avoid driving at night since lights sometimes seem to make things blur.''
- B. ''I take half of the usual dose for my sinuses to maintain my blood pressure.''
- C. ''I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem.''
- D. ''I take extra fiber and drink lots of water to avoid getting constipated.''
Correct answer: ''I take extra fiber and drink lots of water to avoid getting constipated.''
Rationale: The correct answer is ''I take extra fiber and drink lots of water to avoid getting constipated.'' In individuals with glaucoma, activities that involve straining, such as constipation, should be avoided as they can increase intraocular pressure. Choices A, B, and C are incorrect as they do not align with the management of glaucoma. Driving at night or taking sinus medication are not directly related to glaucoma, and sitting by the pool due to an eye problem does not provide information relevant to managing glaucoma.
4. A client with a broken femur is in a traction splint in bed. Which of the following interventions is NOT part of caring for this client?
- A. Palpating the temperature of both feet
- B. Evaluating pulses bilaterally
- C. Turning the client to a side-lying position
- D. Relieving heel pressure by placing a pillow under the foot
Correct answer: C: Turning the client to a side-lying position
Rationale: When caring for a client with a broken femur in a traction splint, turning the client to a side-lying position is not recommended. This client is at risk of skin breakdown and complications due to the injury, making it important to prevent unnecessary movement that may increase the risk of injury or discomfort. Palpating the temperature of both feet helps in assessing circulation, evaluating pulses bilaterally ensures perfusion to the extremities, and relieving heel pressure by placing a pillow under the foot helps in reducing pressure points and preventing complications like pressure ulcers. Therefore, the correct answer is turning the client to a side-lying position as it is not a recommended intervention in this scenario.
5. A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breastfeed the infants. Which of the following is based on sound rationale?
- A. Nursing will help contract the uterus and reduce your risk of bleeding.
- B. Breastfeeding twins will take too much energy after the hemorrhage.
- C. The blood transfusion may increase the risks to you and the babies.
- D. Lactation should be delayed until the 'real milk' is secreted.
Correct answer: Nursing will help contract the uterus and reduce your risk of bleeding.
Rationale: The correct answer is 'Nursing will help contract the uterus and reduce your risk of bleeding.' Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage. Choice B is incorrect because breastfeeding can actually help prevent further bleeding by promoting uterine contractions. Choice C is incorrect as the blood transfusion is aimed at restoring the client's blood volume and should not significantly impact the babies. Choice D is incorrect as lactation should not be delayed, as breastfeeding can provide numerous benefits to both the mother and infants, including aiding in the prevention of postpartum hemorrhage.
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