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
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. Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?
- A. Taking a health history and performing a physical exam prior to the procedure
- B. Instructing the client about how to care for his colostomy stoma
- C. Developing goals that state the client will ambulate three times a day
- D. Determining that the client may need more support at home after dismissal
Correct answer: B
Rationale: The intervention stage of the individualized nursing care plan is where the nurse provides care, treatments, or education to help the client meet the devised outcomes. Instructing the client about how to care for his colostomy stoma is the correct example of an intervention as it directly involves providing education and guidance to the client on post-operative care. This intervention supports the process of helping the client meet the outcomes designed for this case, which is to enable the client to properly care for his colostomy after a bowel resection. The other options do not directly involve interventions aimed at assisting the client in meeting the specific care needs related to the colostomy procedure.
3. Albert B. is incontinent of urine. He also wears glasses and hearing aids. His ____________lead(s) to his risk for falls.
- A. incontinence and loss of vision
- B. loss of vision
- C. incontinence
- D. loss of hearing
Correct answer: B
Rationale: Albert B. is at risk for falls due to two factors: his incontinence and his loss of vision. Loss of vision significantly impairs one's ability to navigate and avoid obstacles, thereby increasing the risk of falls. While incontinence is a risk factor for falls, the primary concern in this case is the loss of vision since it directly affects balance and safety. Therefore, the correct answer is 'loss of vision.' Choices A, C, and D are incorrect because they do not address the key factor of impaired vision leading to the risk of falls.
4. A complication of osteoporosis is _______________?
- A. rheumatoid arthritis
- B. gouty arthritis
- C. dorsiflexion
- D. joint deformity
Correct answer: D
Rationale: Joint deformity is a well-known complication of osteoporosis, leading to structural changes in the joints due to bone loss and fragility. Gouty arthritis and rheumatoid arthritis are distinct types of arthritis that are not direct complications of osteoporosis. Dorsiflexion is a movement related to the foot's range of motion and is not a typical complication of osteoporosis.
5. What question must the nurse ask when formulating a nursing diagnosis?
- A. What diagnosis did the physician make for this client?
- B. What is the issue that I can solve for this client?
- C. What physician orders will resolve this issue?
- D. What underlying disease does this client have?
Correct answer: B
Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.
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