NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. A patient works with a nurse to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action?
- A. Remain silent.
- B. Educate the patient that the outcome is not realistic.
- C. Explore with the patient possible consequences of the outcome.
- D. Formulate an appropriate outcome without the patient's input.
Correct answer: C
Rationale: In this scenario, the nurse should collaborate with the patient rather than impose personal opinions. While the nurse should respect the patient's autonomy, they also have a duty to provide guidance. By exploring possible consequences of the suggested outcome with the patient, the nurse can facilitate a discussion that helps the patient make an informed decision. This approach respects the patient's input while ensuring their well-being. Remaining silent (Choice A) may not address the issue, educating the patient unilaterally (Choice B) may be perceived as dismissive, and formulating an outcome without patient input (Choice D) disregards the patient's autonomy and preferences.
2. The Atlas and the Axis are:
- A. found in the vertebrae.
- B. described as being cervical.
- C. the first two bones that form the column for the spine on the superior aspect.
- D. All of the above.
Correct answer: D
Rationale: The Atlas and the Axis are the first two cervical vertebrae, designated as C1 and C2. The Atlas (C1) supports the skull, while the Axis (C2) allows for rotation of the skull. Therefore, all the statements in choices A, B, and C are correct, making 'All of the above' the correct answer. Choice A is correct as the Atlas and Axis are indeed found in the vertebrae. Choice B is correct as they are the first two cervical vertebrae. Choice C is correct as these bones form the superior aspect of the spine.
3. During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?
- A. "I can always trust my family."?
- B. "It seems like I always have bad luck."?
- C. "You never know who will turn against you."?
- D. "I hear evil voices that tell me to do bad things."?
Correct answer: D
Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis. Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.
4. Which principle of body mechanics may help to reduce the risk of a back injury?
- A. Maintain a wide base of support
- B. Bend from the knees, not the waist
- C. Keep the back straight while lifting
- D. Push or pull objects rather than lifting
Correct answer: C
Rationale: Proper body mechanics are crucial to prevent injuries, especially for professions involving lifting and moving objects. Keeping the back straight while lifting is essential to reduce the risk of back injuries as it helps maintain the spine's natural alignment and prevents excessive strain on the back muscles. Choosing choices A, B, and D would increase the risk of back injury. Maintaining a wide base of support provides stability, bending from the knees instead of the waist protects the lower back, and pushing or pulling objects reduces the strain on the back muscles, all contributing to preventing back injuries.
5. A patient's Foley catheter has been discontinued. You will dispose of this patient equipment by doing which of the following?
- A. Wearing gloves and then placing this equipment in the regular trash can after it is placed in a paper bag.
- B. Simply placing this equipment in the regular trash can after it is placed in a paper bag.
- C. Wearing gloves and then placing this equipment into a special 'hazardous waste' container.
- D. Simply placing this equipment in the 'hazardous waste' container after it is placed in a paper bag.
Correct answer: C
Rationale: When disposing of used patient equipment, such as a Foley catheter, that has come in contact with bodily fluids, it is considered hazardous waste. The correct procedure involves wearing gloves and placing the Foley bag and tubing into a special 'hazardous waste' container. This container is marked as 'Hazardous' and is typically red to indicate the potential danger of its contents. Placing the equipment in a regular trash can, even if placed in a paper bag, is not appropriate as it does not meet the standards for disposing of hazardous waste. Therefore, options A and B are incorrect. Similarly, simply placing the equipment in a 'hazardous waste' container after it is placed in a paper bag is also incorrect as direct disposal into the designated container while wearing gloves is the proper protocol, making option D incorrect.
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