Saunder's Comprehensive NCLEX Review Practice Questions
The nurse is planning care for a client of 1. Safe sleeping
Native Hawaiian descent who recently had a
baby. The nurse develops a teaching plan and Rationale: The native Hawaiian population has a
includes info about which measure that's disproportionately higher rate of infant mortality compared with
related to a newborn complication within this other ethnic groups. Sudden Infant Death Syndrome (SIDS) is a
ethnic group? major cause of infant mortality. Safe sleeping is an important
1. safe sleeping measure to prevent this newborn complication.
2. car seat safety
3. breast-feeding
4. baby-proofing
The nurse is planning care for an assigned 2. MSM
client. The nurse should include info in the
plan of care about the prevention of HIV for Rationale: MSM (men who have sex with men) are at a higher
which individuals specifically at risk? risk for HIV and AIDS.
1. lesbian persons
2. men-who-have-sex-with-men (MSM)
3. women-who-have-sex-with-women (WSW)
4. Female-To-Male (FTM) transgender
persons
Which therapeutic communication technique 1. Using open-ended questions
is most helpful when working with
transgender persons? Rationale: The use of open-ended questions is the most helpful
1. using open-ended questions in communicating with transgender persons because it assists in
2. using their first name to address them refraining from judgment and allows the client the opportunity
3. using pronouns associated with birth sex to express their thoughts and feelings.
4. anticipating the client's needs and making
suggestions
,Which special population should be targeted 1, 2, 4, 5
for breast cancer screening by way of
mammography? Select all that apply: Rationale: Transgender persons who have undergone sexual
1. male-to-female (MTF) reassignment surgery should have the respective preventive
2. female-to-male (FTM) screenings. WSW and WSM should also have screenings.
3. men-who-have-sex-with-men (MSM)
4. women-who-have-sex-with-men (WSM)
5. women-who-have-sex-with-women (WSW)
The nurse working in a correctional facility is 3. "living in a prison can predispose a person to different health
caring for a new prisoner. The client asks conditions"
about health risks associated with living in a
prison. How should the nurse respond? Rationale: the environment of a prison can predispose a person
1. "health care is very limited in the prison to different health conditions. Option 1 does not address the
setting" client's question and options 2 and 4 convey incorrect
2. "living in a prison isn't different than living information.
at home"
3. "living in a prison can predispose a person
to different health conditions"
4. "living in a prison is similar to living in a
condominium complex or dorm"
A nurse working in a community outreach 3, 4, 5, 6
program for foster children plans care
knowing that which health conditions are Rationale: foster children are at risk for a variety of health
common in this population? Select all that conditions later in life, including ADHD, aggressive behavior,
apply: anxiety disorder, bipolar disorder, depression, mood disorder,
1. asthma PTSD, reactive detachment disorder, sleep problems, prenatal
2. claustrophobia drug and alcohol exposure, and personality disorder.
3. sleep problems Claustrophobia and asthma are not specifically associated with
4. bipolar disorder foster children.
5. aggressive behavior
6. ADHD
,The nurse is caring for a female client in the 3. a reddish-purple mark on the neck
ED who presents with a complaint of fatigue
and SOB. Which physical assessment findings, Rationale: The client should be screened for abuse. Battered
if noted by the nurse, warrant a need for women experience bruises, particularly around the eyes, red or
follow up? purple marks on the neck, sprained or broken wrists, chronic
1. reddened sclera of the eyes fatigue, SOB, muscle tension, involuntary shaking, changes in
2. dry flaking noted on the scalp eating and sleeping, sexual dysfunction, and fertility issues.
3. a reddish-purple mark on the neck Mental health issues can also arise including PTSD, nightmares,
4. a scaly rash noted on the elbows and anxiety, uncontrollable thoughts, depression, anxiety, low self-
knees esteem, and alcohol and drug abuse. Reddened sclera, a dry
rash on the elbows, and flaking of the scalp do not indicate
abuse.
The nurse hears a client calling out for help, 3. the client was found lying on the floor
hurries down the hallway to the client's room,
and finds the client lying on the floor. The Rationale: The occurrence report should contain a factual
nurse performs an assessment, assists the description of the occurrence, any injuries experienced by
client back to bed, notifies the health care those involved, and the outcome of the situation. The other
provider of the incident, and completes an options are interpretations of the situation, not facts.
incident report. Which statement should the
nurse document on the incident report?
1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to get
out of bed.
, A client is brought to the ED by emergency 3. transport the victim to the operating room for surgery
medical services (EMS) after being hit by a
car. The name of the client is unknown, and Rationale: two situations where informed consent is not needed
the client has sustained a severe head injury are when an emergency is present and delaying treatment in
and multiple fractures and is unconscious. An order to get informed consent would result in injury or death to
emergency craniotomy is required. Regarding the client, or when the client waives the right to get informed
informed consent for the surgical procedure, consent.
which is the best action?
1. obtain a court order for the surgical
procedure
2. ask the EMS team to sign the informed
consent
3. transport the victim to the operating room
for surgery
4. call the police to identify the client and
notify the family
A nurse has just assisted a client back to bed 1. reassess the client
after a fall. The nurse and primary healthcare
provider have assessed the client and have Rationale: after a client's fall, the nurse must frequently reassess
determined that the client is not injured. After the client. Their fall should be treated as private information and
completing the occurrence report, the nurse given on a "need to know" basis. The nurse does not need to
should implement which action next? put the completion of the occurrence report in the nurse's
1. reassess the client notes.
2. conduct a staff meeting to describe the fall
3. contact the nursing supervisor to update
info regarding the fall
4. document in the nurse's notes that an
occurrence report was completed
The nurse is planning care for a client of 1. Safe sleeping
Native Hawaiian descent who recently had a
baby. The nurse develops a teaching plan and Rationale: The native Hawaiian population has a
includes info about which measure that's disproportionately higher rate of infant mortality compared with
related to a newborn complication within this other ethnic groups. Sudden Infant Death Syndrome (SIDS) is a
ethnic group? major cause of infant mortality. Safe sleeping is an important
1. safe sleeping measure to prevent this newborn complication.
2. car seat safety
3. breast-feeding
4. baby-proofing
The nurse is planning care for an assigned 2. MSM
client. The nurse should include info in the
plan of care about the prevention of HIV for Rationale: MSM (men who have sex with men) are at a higher
which individuals specifically at risk? risk for HIV and AIDS.
1. lesbian persons
2. men-who-have-sex-with-men (MSM)
3. women-who-have-sex-with-women (WSW)
4. Female-To-Male (FTM) transgender
persons
Which therapeutic communication technique 1. Using open-ended questions
is most helpful when working with
transgender persons? Rationale: The use of open-ended questions is the most helpful
1. using open-ended questions in communicating with transgender persons because it assists in
2. using their first name to address them refraining from judgment and allows the client the opportunity
3. using pronouns associated with birth sex to express their thoughts and feelings.
4. anticipating the client's needs and making
suggestions
,Which special population should be targeted 1, 2, 4, 5
for breast cancer screening by way of
mammography? Select all that apply: Rationale: Transgender persons who have undergone sexual
1. male-to-female (MTF) reassignment surgery should have the respective preventive
2. female-to-male (FTM) screenings. WSW and WSM should also have screenings.
3. men-who-have-sex-with-men (MSM)
4. women-who-have-sex-with-men (WSM)
5. women-who-have-sex-with-women (WSW)
The nurse working in a correctional facility is 3. "living in a prison can predispose a person to different health
caring for a new prisoner. The client asks conditions"
about health risks associated with living in a
prison. How should the nurse respond? Rationale: the environment of a prison can predispose a person
1. "health care is very limited in the prison to different health conditions. Option 1 does not address the
setting" client's question and options 2 and 4 convey incorrect
2. "living in a prison isn't different than living information.
at home"
3. "living in a prison can predispose a person
to different health conditions"
4. "living in a prison is similar to living in a
condominium complex or dorm"
A nurse working in a community outreach 3, 4, 5, 6
program for foster children plans care
knowing that which health conditions are Rationale: foster children are at risk for a variety of health
common in this population? Select all that conditions later in life, including ADHD, aggressive behavior,
apply: anxiety disorder, bipolar disorder, depression, mood disorder,
1. asthma PTSD, reactive detachment disorder, sleep problems, prenatal
2. claustrophobia drug and alcohol exposure, and personality disorder.
3. sleep problems Claustrophobia and asthma are not specifically associated with
4. bipolar disorder foster children.
5. aggressive behavior
6. ADHD
,The nurse is caring for a female client in the 3. a reddish-purple mark on the neck
ED who presents with a complaint of fatigue
and SOB. Which physical assessment findings, Rationale: The client should be screened for abuse. Battered
if noted by the nurse, warrant a need for women experience bruises, particularly around the eyes, red or
follow up? purple marks on the neck, sprained or broken wrists, chronic
1. reddened sclera of the eyes fatigue, SOB, muscle tension, involuntary shaking, changes in
2. dry flaking noted on the scalp eating and sleeping, sexual dysfunction, and fertility issues.
3. a reddish-purple mark on the neck Mental health issues can also arise including PTSD, nightmares,
4. a scaly rash noted on the elbows and anxiety, uncontrollable thoughts, depression, anxiety, low self-
knees esteem, and alcohol and drug abuse. Reddened sclera, a dry
rash on the elbows, and flaking of the scalp do not indicate
abuse.
The nurse hears a client calling out for help, 3. the client was found lying on the floor
hurries down the hallway to the client's room,
and finds the client lying on the floor. The Rationale: The occurrence report should contain a factual
nurse performs an assessment, assists the description of the occurrence, any injuries experienced by
client back to bed, notifies the health care those involved, and the outcome of the situation. The other
provider of the incident, and completes an options are interpretations of the situation, not facts.
incident report. Which statement should the
nurse document on the incident report?
1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to get
out of bed.
, A client is brought to the ED by emergency 3. transport the victim to the operating room for surgery
medical services (EMS) after being hit by a
car. The name of the client is unknown, and Rationale: two situations where informed consent is not needed
the client has sustained a severe head injury are when an emergency is present and delaying treatment in
and multiple fractures and is unconscious. An order to get informed consent would result in injury or death to
emergency craniotomy is required. Regarding the client, or when the client waives the right to get informed
informed consent for the surgical procedure, consent.
which is the best action?
1. obtain a court order for the surgical
procedure
2. ask the EMS team to sign the informed
consent
3. transport the victim to the operating room
for surgery
4. call the police to identify the client and
notify the family
A nurse has just assisted a client back to bed 1. reassess the client
after a fall. The nurse and primary healthcare
provider have assessed the client and have Rationale: after a client's fall, the nurse must frequently reassess
determined that the client is not injured. After the client. Their fall should be treated as private information and
completing the occurrence report, the nurse given on a "need to know" basis. The nurse does not need to
should implement which action next? put the completion of the occurrence report in the nurse's
1. reassess the client notes.
2. conduct a staff meeting to describe the fall
3. contact the nursing supervisor to update
info regarding the fall
4. document in the nurse's notes that an
occurrence report was completed
