you are caring for a hispanic patient who is scheduled for surgery in the morning a member of the surgery staff is in a hurry when she visits the pati

NCLEX-RN

NCLEX RN Practice Questions With Rationale

1. You are caring for a Hispanic patient who is scheduled for surgery in the morning. A member of the surgery staff is in a hurry when she visits the patient to obtain surgical consent. You know that the patient speaks limited English and can see that he does not really understand what's being said. What is the most appropriate next action?

A. Call a family member to interpret
B. Consult the hospital translator to assist
C. Allow the consent to be signed
D. Ask the staff member to come back later

Correct answer: B

Rationale: Consulting the hospital translator is the most reliable means of ensuring accuracy in the information that the patient is receiving. Family members can be helpful, but they may have difficulty understanding the medical procedures well enough to explain them accurately and may misinterpret the message. Relying on family members could lead to misunderstandings or miscommunication. Allowing the consent to be signed without ensuring the patient's full understanding could pose risks to the patient's well-being. Asking the staff member to come back later delays the essential communication process needed before surgery. Therefore, consulting the hospital translator is the best course of action to ensure clear and accurate communication, especially in critical healthcare decisions like surgical consent.

2. A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

A. Duchenne is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.
B. Duchenne is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.
C. Each child has a 1 in 4 (25%) chance of developing the disorder.
D. Sons only have a 1 in 4 (25%) chance of developing the disorder.

Correct answer: A

Rationale: The correct answer is that Duchenne is an X-linked recessive disorder, meaning the affected gene is located on one of the two X chromosomes of a female carrier. If a son receives the X chromosome bearing the gene, he will develop the disease, giving him a 50% chance of being affected. Daughters, on the other hand, are not affected by Duchenne but have a 50% chance of being carriers since they inherit one copy of the defective gene from the mother. The other X chromosome is inherited from the father, who cannot be a carrier. Therefore, choice A is accurate. Choice B is incorrect because daughters do not develop the disease, and sons have a 50% chance of developing, not both having a 50% chance. Choice C is incorrect as it does not consider the X-linked inheritance pattern of Duchenne. Choice D is inaccurate as it incorrectly states that only sons have a 25% chance of developing the disorder, omitting the carrier status of daughters.

3. You are on the unit and overhear another nurse talking on the phone to a patient's friend who wants to see her patient who is comatose and on a ventilator. Since you cared for that patient yesterday, you know that the patient's significant other, who is also the designated healthcare surrogate (HCS) and has power of attorney (POA), has expressly stated that he wants this person on the list for restricted visitors. The nurse whispers that she'll call him to visit as soon as the significant other has gone home. What should your first response be?

A. Inform the significant other
B. Report the nurse to the nurse manager
C. Speak with the nurse directly in private
D. Call the visitor and tell him he can't visit

Correct answer: C

Rationale: Speaking with the nurse directly and privately is the most constructive manner in which to handle this situation and advocate for the significant other's wishes. Doing so will open communication with a peer and build the relationship, instead of alienating the other nurse by taking action that does not involve her and will cast her in a negative light with others. It is essential to express your concerns regarding honoring the significant other's requests and rights regarding the limitation of visitors. Option A is incorrect because the significant other is not the one trying to visit, and it is more appropriate to address the nurse directly first. Option B is not the best initial response as it may escalate the situation without giving the nurse a chance to correct the issue. Option D is incorrect as it does not address the issue at its source and may create further conflict without resolving the underlying problem.

4. The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to:

A. Excessive fetal weight
B. Low blood sugar levels
C. Depletion of subcutaneous fat
D. Progressive placental insufficiency

Correct answer: D

Rationale: A postmature or postterm pregnancy occurs when a pregnancy exceeds the typical term of 38 to 42 weeks. In this situation, the fetus is at risk due to progressive placental insufficiency. This occurs because the placenta loses its ability to function effectively after 42 weeks. The accumulation of calcium deposits in the placenta reduces blood perfusion, oxygen supply, and nutrient delivery to the fetus, leading to potential growth problems. Choices A, B, and C are incorrect because excessive fetal weight, low blood sugar levels, and depletion of subcutaneous fat are not the primary risks associated with postmature fetuses. The main concern lies in the compromised placental function and its impact on fetal well-being.

5. What ethical principle has led to the need for informed consent?

A. Autonomy
B. Justice
C. Fidelity
D. Beneficence

Correct answer: A

Rationale: Autonomy is the ethical principle that emphasizes an individual's right to make their own decisions if they are mentally competent. Informed consent is a direct result of this principle, as it ensures that patients are fully informed before agreeing to any medical intervention. Autonomy is crucial in healthcare as it respects patients' rights and promotes self-determination. Justice, fidelity, and beneficence are important ethical principles in healthcare, but they do not directly lead to the need for informed consent. Justice focuses on fairness and equal treatment, fidelity on trustworthiness and loyalty, and beneficence on doing good for the patient's benefit.