NCLEX RN Practice Test

Providing information about recent changes in the client's vital signs is the most critical detail to include during the hand-off report. Any significant alterations in vital signs can signal potential complications, like infection or deterioration of the client’s condition, that require immediate attention or monitoring. While knowledge of discharge plans, family support, and dietary preferences might be useful, these details are not as critical in ensuring immediate patient safety. Proper prioritization in hand-offs focuses on clinical conditions and urgent concerns to avoid errors.

Urine output consistently below 30 mL/hour in an adult is often a sign of diminished kidney function, dehydration, or compromised fluid balance, all of which require prompt evaluation and targeted interventions. Notifying the healthcare provider is the safest and most appropriate step because it allows for further diagnostic evaluation and treatment adjustments, such as modifying fluid administration or addressing potential renal impairment. Increasing the fluid administration rate without an order can lead to complications such as fluid overload. Waiting to monitor further can delay treatment and exacerbate the issue. Administering a diuretic without understanding the underlying cause could harm the patient, as decreased urine output might indicate hypovolemia rather than fluid overload.

The correct answer is for the nurse to take the time to acknowledge the client’s feelings and offer reassurance while providing a calming strategy. This approach demonstrates therapeutic communication, validates the patient’s emotional state, and creates trust. Remaining nearby but respecting boundaries is critical to promoting a sense of safety. Administering a medication without first attempting non-pharmacologic strategies fails to address the root cause of the client's behavior or feelings and should not be the first step. Ignoring the behavior or demanding that the client settle down is dismissive and does not foster a supportive environment. Contacting security to monitor the client prematurely escalates the situation, which could increase their distress or sense of unsafety.

The client with the respiratory rate of 32 breaths per minute and oxygen saturation of 88% is the highest priority. This client shows signs of significant respiratory distress and requires immediate intervention to prevent further deterioration. The other clients, although having important needs, exhibit conditions that are less life-threatening and allow for delayed assessment without causing immediate harm. Prioritization in nursing follows frameworks like "ABC" (Airway, Breathing, Circulation), making respiratory issues an urgent focus.

The correct answer emphasizes both client safety and effective use of the walker to prevent falls. It encourages the client to maintain a clear walking path, which reduces the risk of tripping or stumbling due to clutter. Encouraging rubber-tipped ends on walkers, installing grab bars, and removing rugs are also important safety precautions but go beyond the scope of this specific teaching session. These aspects might require additional instructions or referrals for home modifications.

The correct action is to use short, simple sentences. This technique minimizes confusion and enhances the client's ability to understand. Speaking loudly can be agitating and is not helpful unless a hearing impairment is present. Asking open-ended questions can be overwhelming and frustrating for a client with advanced dementia, who may struggle with memory and forming complex thoughts; closed-ended questions are preferred. Using complex medical terminology would further impair communication and is inappropriate.

Collaborating with stakeholders such as parents, teachers, and local health organizations ensures that the education program aligns with the needs and resources of the community. By incorporating diverse perspectives and support systems, the program is more likely to be relevant, actionable, and sustainable. The other options are less effective because focusing on one standard, choosing a specific diet, or applying generic plans to multiple communities does not adequately address the unique needs and challenges of the targeted population.

The correct answer is to prioritize patient safety by implementing the RACE protocol: Rescue, Activate the alarm, Confine the fire, and Extinguish/Evacuate. The first action is to rescue the patient in immediate danger and bring them to a safe location. Following this, activating the fire alarm ensures that additional help is summoned. Although extinguishing the fire and notifying other staff are important, they come only after the patient is secured and the alarm is raised. Closing the doors is also critical but must be done after removing the patient to avoid putting them in further danger.

The correct answer focuses on actions that establish trust and a sense of safety for the client in the therapeutic environment. Approaching the client calmly and offering a non-threatening presence encourages the client to feel supported and accepted without applying pressure. Encouraging participation in group activities may be too overwhelming for the client in their current state, and observing without interaction does not foster a connection or therapeutic relationship. Redirecting the client to sit down and rest imposes control unnecessarily and may escalate anxiety, as pacing can sometimes be a self-soothing behavior.

To support adherence, the nurse should collaborate with the client to develop strategies, such as using a weekly medication organizer, to make medication management easier and more consistent. This empowers the client to engage in their own care. Suggesting reliance on memory ignores the common cognitive challenges associated with aging. Encouraging a family member to take over responsibility bypasses the client's autonomy. Lastly, scolding the client fails to build trust or address their stated concern.

Proper labeling of the specimen at the client's bedside after collection is a critical safety step to prevent laboratory errors. This ensures that the specimen is accurately matched to the client and reduces the risk of misidentification or mix-ups that could compromise diagnostic accuracy. Other actions, such as ensuring aseptic technique, properly applying the tourniquet, or confirming the requisition form, are essential procedural steps but do not directly address error prevention in handling or processing the specimen.

Delegation must align with the team member’s training and scope of practice. Licensed practical/vocational nurses are equipped to perform tasks such as administering oral medications and providing routine treatments, which the nurse is ultimately responsible for overseeing. Tasks involving patient assessment or education require the nurse’s clinical judgment and are beyond the scope of the LPN/VN. The option involving monitoring saturation levels regularly may seem reasonable, but monitoring in this way typically aligns with the duties of an assistive personnel under indirect supervision, not the LPN/VN.

The correct answer is increasing ambulation, as it helps stimulate peristalsis and promotes natural bowel motility, which is often slowed after surgery. This is a first-line, non-invasive intervention that prioritizes the client's safety while addressing the issue effectively. Administering a laxative or offering an enema might be considered later if conservative measures like increased activity and hydration fail but are not initial steps. Managing oral fluid intake to avoid abdominal distension is incorrect because limiting fluids can exacerbate constipation rather than resolving it.

The client with an oxygen saturation of 88 % on room air exhibits a breathing problem that can quickly become life-threatening if not corrected. According to the ABC (Airway, Breathing, Circulation) priority framework, breathing issues take precedence over pain control, IV site management, and routine dressing care. The other clients' needs are important but do not pose an immediate threat to life and can be addressed after stabilizing the client with hypoxemia.

The correct answer is to assess oxygen saturation with a pulse oximeter. In a scenario where a client displays signs of respiratory distress, nursing priorities follow the Airway, Breathing, Circulation (ABC) model. Since the client can still speak (indicating a patent airway), assessing the effectiveness of breathing and oxygen delivery through pulse oximetry becomes the priority. This provides objective data to determine the need for oxygen therapy or other interventions.

Other options such as administering oxygen and elevating the head of the bed may be appropriate secondary actions but should follow the assessment of oxygen saturation. Administering oxygen without knowing the saturation level could delay identifying and addressing the underlying issue. Similarly, auscultating lung sounds is a valuable assessment but has lower priority than determining the client’s oxygenation status.