2023 RN test 3 NCLEX ALL questions and highlighted answers with rationales (rated 100%)

2023 RN test 3
NCLEX ALL
questions and
highlighted
answers with
rationales (rated
100%)

The charge nurse overhears an AP yelling loudly to a patient
who is hard of hearing, while transferring them from the bed to a
chair. Upon entering the room, which response by the charge
nurse is most appropriate?
a. "Please speak more quietly so you don't disturb the other
patients."
b. "Let me help you with your transfer technique."
c. "When you are finished, be sure to apologize for shouting."
d. "When your patient is safe and comfortable, meet me at the
desk." - ANSWER-d.
rationaleThe charge nurse should direct the AP to see to the
patient's safety, then address any concerns privately. The nurse
then can discuss appropriate use of therapeutic communication.
A public health nurse is leaving the home of a young mother
who has an infant with special needs. The neighbor states,
"How is she doing, since the baby's father is no help?" What is
the nurse's best response?
a. "New mothers need support."
b. "The lack of a father is difficult."
c. "How are you today?"
d. "It is a very sad situation." - ANSWER-a.
rationale-The nurse must maintain confidentiality when providing
care. The statement "New mothers need support" is a general
statement that all new parents need help. The statement is not
judgmental of the family's roles. "How are you today?" is
dismissive of the neighbor's question.
A toddler with vomiting, diarrhea, and dehydration is being seen
at an acute care center. During the admission interview, what
question will the nurse ask the parents to elicit the most useful
information?
a. "Watching your child vomiting and in discomfort must have
been scary."
b. "This started yesterday, correct?"
c. "Has this child has had anything to drink?"
d. Could you tell me the color and approximate amount of the
vomiting? - ANSWER-d.
rationale-Using a clarifying question or comment allows the
nurse to gain an understanding of the parents' observations,
avoiding misunderstandings that could lead to an inappropriate
nursing diagnosis. A reflective question technique involves
repeating what the person has said or describes the person's
feelings. Assertive questions are direct, demonstrating the ability
to stand up for self or others, using open and honest
communication. Open-ended questions encourage free
verbalization and expression of what the parents believe to be
true.
A nurse enters a patient's room and examines the patient's
intravenous (IV) fluids and cardiac monitor. When asked, "who
are you?", which response by the nurse is most appropriate?
a. "I'm just the IV therapist checking your IV."
b. "I've been transferred to this division and will be caring for
you."
c. "I'm sorry, my name is John Smith and I am your nurse."
d. "I am John Smith, your nurse, and I'll be caring for you until
11 PM." - ANSWER-d.
rationale-The nurse should identify themselves, ensure the
patient knows what will be happening, and the duration of their
relationship.
A nurse enters the room of a patient with cancer. The patient is
crying and states, "I feel so alone." How will the nurse best
communicate a therapeutic response?
a. The nurse stands at the patient's bedside and states, "I
understand how you feel. My mother said the same thing when
she was ill."
b. The nurse places a hand on the patient's arm and states,
"You feel so alone."
c. The nurse stands in the patient's room and asks, "Why do you
feel so alone? Your wife has been here every day."
d. The nurse holds the patient's hand and asks, "Tell me what
feeling so alone is like for you?" - ANSWER-d.
rationale- The use of touch conveys acceptance, and the
implementation of an open-ended question allows the patient
time to verbalize freely.
A primary nurse is preparing a discharge plan for a patient who
has been hospitalized following a double mastectomy. Which
statement is most appropriate for the nurse to use in the
termination phase of the therapeutic relationship?
a. "Let's review the progress you've made in meeting your
goals."
b. "I'd like to review your medication schedule with you."
c. "I need to document today's teaching session in the electronic
health record."
d. "Should we include your family in today's session?" -
ANSWER-a.
rationale-The termination phase occurs when the conclusion of
the initial agreement is acknowledged. Discharge planning
correlates with the termination phase of a therapeutic
relationship and the progress toward the patient's goals are
reviewed.
A nursing student is nervous and concerned about working at a
clinical facility. Which action would best decrease anxiety and
help ensure successful delivery of patient care?
a. Determining the established goals of the institution
b. Ensuring that verbal and nonverbal communication is
congruent
c. Engaging in self-talk to plan the day and decrease fear
d. Speaking with fellow colleagues about how they feel -
ANSWER-c.
rationale-By engaging in positive self-talk, or intrapersonal
communication, the nursing student can plan the day, decrease
fear and anxiety, and enhance clinical performance.
A nurse says to their nurse manager, "I need the day off, and
you didn't give it to me!" The manager replies, "I wasn't aware
you needed the day off, and it isn't possible since staffing is
inadequate." How could the nurse best modify the
communication for a more positive interaction?
a. "I placed a request to have 8th of August off for a doctor's
appointment, but I'm scheduled to work."
b. "Could I make an appointment to discuss my schedule with
you? I requested the 8th of August off for a doctor's
appointment."
c. "I will need to call in on the 8th of August because I have a
doctor's appointment."
d. "Since you didn't give me the 8th of August off, will I need to
find someone to work for me?" - ANSWER-b.
rationale-Effective communication involves sending clear,
nonthreatening, and respectful information to the receiver. The
nurse identifies the subject of the meeting and determines a
mutually agreed upon time.
During a nursing staff meeting to discuss delayed
documentation, the nurses unanimously agree that they will
ensure all vital signs are reported and charted within 15 minutes
following assessments. This decision is consistent with which
characteristics of effective communication? Select all that apply.
a. Group decision making
b. Group leadership
c. Group power
d. Group identity
e. Group patterns of interaction
f. Group cohesiveness - ANSWER-a, d, e, f.
rationale- Solving problems involves group decision making;
ascertaining the task is important and agreeing to complete the
task on time is characteristic of group identity. Group patterns of
interaction involve honest communication and member support;
cohesiveness occurs when members generally trust each other,
have a high commitment to the group, and a high degree of
cooperation. Group leadership occurs when groups use
effective styles of leadership to meet goals; with group power,
sources of power are recognized and appropriately used to
accomplish group outcomes.
A nurse notices a patient is walking to the bathroom with a
stooped gait, facial grimacing, and grunting sounds. Based on
these nonverbal cues, what action will the nurse take next?
a. Assess for pain and the need for analgesia.
b. Ask the patient if they feel anxious.
c. Offer to sit with the patient and listen to their feelings.
d. Suggest the patient increase their fluid intake to prevent
constipation. - ANSWER-a.
rationale-A patient who presents with nonverbal communication
of a stooped gait, facial grimacing, and grunting sounds is most
likely communicating pain. The nurse should clarify this
nonverbal behavior.
A nursing student is preparing to administer morning care to a
patient. What question by the student is most important to ask?
a. "Would you prefer a bath or a shower?"
b. "May I help you with a bed bath now or later this morning?"
c. "I will be giving you your bath. Do you use soap or shower
gel?"
d. "I prefer a shower in the evening. When would you like your
bath?" - ANSWER-b.
rationale-The nurse should ask permission to assist the patient
with a bath. This allows for patient preferences and consent for
care that involves entering the patient's personal space.
A nurse enters a patient's room and finds them vomiting bright
red blood. After taking vital signs, the nurse communicates the
event to the health care provider using the SBAR format. Which
information will the nurse include in the "A" portion of the SBAR
communication?
Exhibit: Electronic health record (EHR)
Past medical history
Vital Signs
Peptic ulcer
T 98.8°F, P 111, RR 20, BP 98/50
Bleeding disorder
Pulse oximetry 96%
a. Admitted with peptic ulcer and bleeding disorder
b. Found vomiting in bathroom
c. Anti-ulcer medication recommendation
d. Vital signs, oxygen saturation, bright red emesis - ANSWERd. The SBAR method is used to improve hand-off
communication.
Rationale-SBAR, which stands for Situation, Background,
Assessment, and Recommendations, provides a clear,
structured, and easy to use framework. Vital signs, oxygen
saturation, and the presence of emesis and its color are
assessments.
The nurse preceptor and a new graduate nurse on the surgical
unit are performing preoperative assessments on a group of
patients. What statement by the graduate nurse requires the
preceptor to intervene?
a. "I am sure everything will be fine; you have nothing to worry
about."
b. "When you return from surgery, you'll need to cough and
deep breathe."
c. "Many people on this unit have had that procedure with good
success."
d. "You seem fearful, can I answer any questions about the
procedure?" - ANSWER-a.
rationale-Telling a patient that everything will be fine is a cliché.
This statement gives false assurance and may give the patient
the impression that the nurse is dismissive of a patient's
concerns or condition.