NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. A patient is asked to abduct her arms. Which of the following accurately describes her arm movement?
- A. She moves her arms away from her trunk
- B. She moves her arms toward her trunk
- C. She rotates her arms at the wrists while holding them away from her body
- D. She crosses her arms over her abdomen
Correct answer: A
Rationale: Abduction refers to moving a body part away from the midline of the body. In this case, when the patient abducts her arms, she is moving them away from her trunk. Choice A is correct. Choices B, C, and D are incorrect. Choice B describes adduction, which is the movement of a body part toward the midline. Choice C describes wrist rotation, not arm abduction. Choice D describes crossing the arms over the abdomen, which is not the movement associated with abduction.
2. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to
- A. choose low-fat foods from the menu
- B. perform leg exercises hourly while awake
- C. ambulate the evening of the operative day
- D. turn, cough, and deep breathe every 2 hours
Correct answer: D
Rationale: Postoperative nursing care after a cholecystectomy focuses on preventing respiratory complications due to the surgical incision being high in the abdomen, which impairs coughing and deep breathing. Turning, coughing, and deep breathing every 2 hours help prevent respiratory complications, such as pneumonia. While choices A, B, and C are also important aspects of postoperative care, they are not as high a priority as ensuring proper ventilation and respiratory function in the immediate postoperative period.
3. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from?
- A. Cataracts
- B. Glaucoma
- C. Astigmatism
- D. Presbyopia
Correct answer: D
Rationale: Presbyopia is a condition that occurs when the lens of the eye loses accommodation and is unable to focus light on objects nearby. As a result, clients are unable to see or read items up close but may have success when holding the same item at arm's length. Many clients with presbyopia must wear bifocals, but long-distance vision remains unaffected. Cataracts involve clouding of the eye's lens, leading to blurry vision. Glaucoma is associated with increased intraocular pressure that damages the optic nerve, causing vision loss. Astigmatism is a refractive error where the cornea or lens has an irregular shape, leading to distorted or blurred vision.
4. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?
- A. "Ethnicity is dynamic and ever-changing."?
- B. "Ethnicity is the belief in a higher power."?
- C. "Ethnicity pertains to a social group that may possess shared traits such as religion and language."?
- D. "Ethnicity is learned from birth through the processes of language acquisition and socialization."?
Correct answer: C
Rationale: Ethnicity pertains to a social group that may possess shared traits such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Culture is dynamic, ever-changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power. Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.
5. When teaching a patient to use the three-point gait technique of crutch use:
- A. The injured leg moves ahead at the same time as both crutches.
- B. One crutch moves at a time and is then followed by the injured leg.
- C. Both crutches move ahead at the same time followed by both legs at the same time.
- D. None of the above are correct.
Correct answer: A
Rationale: The correct technique for a three-point gait involves the injured leg moving simultaneously with both crutches, followed by the uninjured leg. This gait pattern is utilized when the patient is unable to bear full weight on one of their legs. Choice A accurately describes the appropriate sequence of movements for the three-point gait technique. Choices B and C do not accurately reflect the correct pattern of movement during the three-point gait technique, making them incorrect. Choice D is incorrect as there is a correct option among the choices provided.
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