NCLEX-RN
Saunders NCLEX RN Practice Questions
1. In which situation might an occupational health nurse consultation be necessary?
- A. A nurse is injured from using incorrect body mechanics to lift a client
- B. A nurse receives a subpoena to testify in court about a client's case
- C. A client who has been injured in a diving accident needs assistance with planning rehabilitation and surgery
- D. A nursing unit is implementing a new electronic health record system
Correct answer: A
Rationale: An occupational health nurse is involved in assessing the work environment, educating employees about safety practices, and infection control. When a nurse sustains an injury due to incorrect body mechanics, it falls under the purview of an occupational health nurse because they are responsible for documenting such incidents, providing necessary care or treatment, and ensuring that preventive measures are in place to avoid similar accidents in the future. The other options do not directly relate to the role of an occupational health nurse. Testifying in court, assisting a client with rehabilitation, or implementing a new electronic health record system are not typical scenarios where an occupational health nurse would be involved.
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. Choose the BEST answer. To ensure adequate protection for legal issues, offices should maintain patients' charts for:
- A. 10 years
- B. Forever
- C. Until the age of majority
- D. 2 years after the patient was last seen in the office
Correct answer: B
Rationale: The correct answer is 'Forever.' Maintaining patients' charts indefinitely ensures comprehensive legal protection by having all relevant information available in case of litigation or if patient history needs to be referenced in the future. Choice A, '10 years,' may not be sufficient to cover the entire period within which legal issues may arise. Choice C, 'Until the age of majority,' is not ideal as legal matters may extend beyond this age limit. Choice D, '2 years after the patient was last seen in the office,' is inadequate as legal actions can occur beyond this timeframe, necessitating the need for long-term retention of patient charts.
4. 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.
5. If you are caring for a patient of the Hindu culture, what may you anticipate regarding visitors?
- A. Limited visitors, respectful of privacy
- B. Family members only
- C. Large number of visitors/community support
- D. None of the above
Correct answer: C
Rationale: In Hindu culture, there is a strong sense of community and support. It is common for a patient to receive a large number of visitors, indicative of the community coming together to provide emotional and practical support. This support network is crucial for the patient's well-being and healing process. Option A, limited visitors, is incorrect as the Hindu culture values community involvement. Option B, family members only, is incorrect as the support network extends beyond just family. Option D, none of the above, is incorrect as the Hindu culture typically involves community support and a significant number of visitors.
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