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. While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?

A. The client is choking on part of the tube
B. The client has anxiety
C. The client is having a laryngospasm
D. The client is having a normal response from anesthesia

Correct answer: D

Rationale: After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.

3. You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT:

A. PT referral for development of a planned exercise program
B. Avoidance of prolonged sun exposure
C. Hot baths to promote muscle relaxation
D. Instructions to evaluate the home environment to ensure safety

Correct answer: C

Rationale: Discharge instructions for a patient with newly diagnosed multiple sclerosis should focus on promoting safety and minimizing exacerbations. Hot baths should be avoided as excessive heat can trigger acute symptoms. Therefore, instructions may include PT referral for an exercise program to maintain mobility, avoidance of prolonged sun exposure to prevent symptom exacerbation, and guidance to evaluate the home environment for safety as symptoms progress. Hot baths are not recommended due to the risk of exacerbating symptoms, making it the correct answer. Choices A, B, and D are appropriate for a patient with multiple sclerosis, as they address mobility, symptom management, and safety concerns, respectively.

4. 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.

5. A client is having blood tests and has an elevated lymphocyte level. Based on knowledge of cellular components, what does the nurse know about these cells?

A. Contain histamine and provide protection during allergic reactions
B. Are involved in phagocytosis
C. Provide protection and immunity against foreign substances
D. Carry hemoglobin and oxygen to body tissues

Correct answer: C

Rationale: Lymphocytes are a type of white blood cells that play a crucial role in supporting the body's immune system. They are responsible for producing substances that protect the body against infections and foreign substances that could potentially harm the client. Lymphocytes consist of two main types: T cells, which are produced in the thymus, and B cells, which are produced in the lymphatic tissue. Choice A is incorrect because histamine is mainly associated with basophils and mast cells, not lymphocytes. Choice B is incorrect as phagocytosis is a function of other white blood cells such as neutrophils and macrophages. Choice D is also incorrect as carrying hemoglobin and oxygen is a function of red blood cells, not lymphocytes.