Saunders NCLEX Questions
The nurse has completed teaching a new nursing graduate on how to avoid being judgmental. Which statement by the new nursing graduate would indicate to the nurse that there is a need for further teaching? "I don't think you need to do that." "Tell me about making that decision." "I would like to be sure I understood." "When did you first notice you felt that way?"
"I don't think you need to do that."
The nurse is assigned to the following clients. The nurse would assess the clients in which order of priority? Place the client in the order of priority for assessment. All options must be used.
1 - A client with heart failure who has a 4-lb weight gain since yesterday and is experiencing shortness of breath 2 - A 24-hour postoperative client who had a wedge resection of the lung and has a closed chest tube drainage system 3 - A client admitted to the hospital for observation who has absent bowel sounds 4 - A client who is undergoing surgery for a hysterectomy on the following day
A unit of packed red blood cells has been ordered for a client with low hemoglobin and hematocrit, and typing and crossmatching has been done. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how would the nurse plan the actions to take? Arrange the actions in the order that they would be performed. All options must be used.
1 - Verify the primary health care provider's (PHCP's) prescription for the blood transfusion. 2 - Ensure that an informed consent has been signed. 3 - Insert an 18- or 19-gauge intravenous catheter into the client. 4 - Obtain the unit of blood from the blood bank. 5 - Ask a licensed nurse to assist in confirming blood compatibility and verifying client identity. 6 - Hang the bag of blood.
The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and three assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? A client who requires a bed bath An older client requiring frequent ambulation A client who requires hourly measurement of vital signs A client requiring abdominal wound irrigations and dressing changes every 3 hours
A client requiring abdominal wound irrigations and dressing changes every 3 hours
The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client would the nurse plan to care for first? A client who is ambulatory, demonstrating steady gait A postoperative client who has just received an opioid pain medication A client scheduled for physical therapy for the first crutch-walking session A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C
A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C
The nurse is the first responder at the scene of a six-car crash on a highway. Which victim would the nurse attend to first? A victim experiencing dyspnea A victim experiencing confusion A victim experiencing tachycardia A victim experiencing intense pain
A victim experiencing dyspnea
The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse would take which initial action?
Activate the emergency response plan.
The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? Actual or life-threatening concerns Completing care in a reasonable time frame Time constraints related to the client's needs Obtaining needed supplies to care for the client
Actual or life-threatening concerns
A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? Each staff member is assigned a specific task for a group of clients. A staff member is assigned to determine the client's needs at home and begin discharge planning. A single registered nurse (RN) is responsible for providing care to a group of six clients with the aid of an assistive personnel (AP). An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients.
An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients.
The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. Libel Battery Assault Slander False imprisonment
Battery Assault False imprisonment
The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? Call the police. Cut up the photograph and throw it away. Call the nursing supervisor and report the incident. Call the laboratory and ask for the name of the individual who sent the photograph.
Call the nursing supervisor and report the incident.
The nurse takes a newly admitted client's vital signs, completes an admission assessment history on the client, and assists the client to change into a hospital gown. By completing these tasks, the nurse is demonstrating which role of the nurse?
Caregiver
The nurse is developing client care assignments for a group of assistive personnel (APs). What is the nurse's first step in planning and assigning clients?
Determine what skills can be delegated.
The home health nurse develops a plan of care for the client. Which actions would the nurse plan as a case manager of the client's care?
Organize, manage, and balance health care services needed for the client.
The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply. Provide monetary relief. Provide crisis counseling. Identify and train personnel. Issue presidential declarations. Deploy National Guard troops. Handle inquiries from families.
Provide crisis counseling. Identify and train personnel. Handle inquiries from families.
The nurse is responsible for the care of a client with schizophrenia who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an assistive personnel (AP)? Determining whether the client has consistently been medication compliant Providing distraction for the client by engaging the client in a board game Discussing the frequency and duration of the hallucinations with the client Assisting the client in identifying any new stressors he or she may be experiencing
Providing distraction for the client by engaging the client in a board game
Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse would inform the AP that making this accusation has violated which legal tort?
Slander
The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise? Primary level of prevention Secondary level of prevention Tertiary level of prevention Quaternary level of prevention
Tertiary level of prevention
The nurse witnesses an automobile crash on a highway and stops to provide assistance to the victim. The nurse notes that the client has sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the crash. Which is accurate regarding the nurse's immunity from this suit? The Good Samaritan law will protect the nurse. The Good Samaritan law will not protect the nurse. The Good Samaritan law protects laypersons but not professional primary health care providers (PHCPs). The Good Samaritan law will provide immunity from the suit, even if the nurse has accepted compensation for the care provided.
The Good Samaritan law will protect the nurse.
The charge nurse is planning the assignment for the day. Which factors would the nurse remain mindful of when delegating tasks? Select all that apply. The acuity level of the clients Specific requests from the staff The clustering of the rooms on the unit The number of anticipated client discharges Client needs and workers' needs and abilities
The acuity level of the clients Client needs and workers' needs and abilities
The charge nurse is planning the assignments for the day. Which factors would the nurse remain mindful of when planning the assignments? Select all that apply. The acuity level of the clients Specific requests from the staff The clustering of the rooms on the unit The number of anticipated client discharges The clients' needs and workers' needs and abilities
The acuity level of the clients The clients' needs and workers' needs and abilities
The nurse hears a client calling out for help and finds the client lying on the floor. The nurse performs an assessment and assists the client back to bed. The primary health care provider is notified of the incident, and the nurse completes an incident (occurrence) report. What would the nurse document on the incident report?
The client was found lying on the floor.
The nurse is delegating the morning hygienic care to the assistive personnel (AP). In reviewing the assigned tasks, the nurse would instruct the AP to use an electric razor for which client? The client with severe pain related to osteoporosis The client with hypokalemia related to diuretic therapy The client with thrombocytopenia related to chemotherapy The client with an elevated white blood cell count related to infection
The client with thrombocytopenia related to chemotherapy
The nurse is a responder at the scene of a building collapse. Which victim would the nurse care for first? Victim with an open fracture of the left lower extremity Victim who is crying hysterically and complaining of pain in the right ankle Victim who is unresponsive and not breathing and whose left pupil is fixed and dilated Victim with an apparent chest wall defect and asymmetrical chest wall movement
Victim with an apparent chest wall defect and asymmetrical chest wall movement
The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply. A client with dyspnea A client experiencing sinus rhythm A client receiving oral anticoagulants A client with chronic atrial fibrillation A client experiencing third-degree heart block A client who has not voided since before surgery
A client experiencing sinus rhythm A client receiving oral anticoagulants A client with chronic atrial fibrillation
