NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. A patient who is displaying the defense mechanism of Compensation would:
- A. Refuse to hear unwanted information.
- B. Transfer feelings of negativity to someone else.
- C. Overemphasize behaviors which accommodate for perceived weaknesses.
- D. Place blame on others for personal actions or mistakes.
Correct answer: C
Rationale: The correct answer is 'Overemphasize behaviors which accommodate for perceived weaknesses.' Compensation involves overemphasizing or exaggerating a particular behavior or trait to make up for or cover up perceived weaknesses in oneself. This defense mechanism allows individuals to focus on their strengths rather than acknowledging their shortcomings. Choices A, B, and D are incorrect. Refusing to hear unwanted information relates more to denial, transferring feelings of negativity to someone else is projection, and placing blame on others is an example of the defense mechanism known as externalization.
2. Patients who cannot move in their bed on their own should be turned at least ________________.
- A. once a day
- B. twice a day
- C. every 2 hours
- D. every 4 hours
Correct answer: C
Rationale: Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications. Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.
3. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?
- A. Help the client to get settled and conduct the interview the next morning when the client is rested
- B. Conduct the interview immediately, directing the majority of the questions to the client
- C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns
- D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication
Correct answer: C
Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.
4. Which of the following safety precautions should the nurse discuss when working with an immunocompromised client?
- A. Avoid canned foods and increase consumption of fresh fruits and vegetables
- B. Hand-wash utensils after use and allow them to air dry
- C. Only drink tap water that has been filtered or boiled before consumption
- D. Never eat meals prepared in restaurants
Correct answer: C
Rationale: The correct answer is to only drink tap water that has been filtered or boiled before consumption. Immunocompromised clients are susceptible to infections, so it is essential to take precautions to prevent exposure to harmful pathogens. Drinking tap water that has been filtered or boiled helps eliminate potential pathogens that could be harmful to the client's health. Choices A, B, and D do not directly address the issue of avoiding potential pathogens that could compromise the health of an immunocompromised client. Thus, they are incorrect. Hand-washing utensils, avoiding canned foods, and increasing fruit and vegetable consumption are good general hygiene practices but may not specifically address the needs of an immunocompromised client.
5. One major difference between long term care and respite centers is the fact that long term care facilities:
- A. provide both physical and emotional care on an ongoing basis, while respite centers offer only temporary services.
- B. provide care for residents on a long-term basis, while respite centers offer only outpatient services.
- C. provide care for residents on a long-term basis, while respite centers offer only temporary services.
- D. There is no difference. Long-term care and respite care are the same.
Correct answer: C
Rationale: The major difference between long-term care and respite centers is that long-term care facilities provide both physical and emotional care on an ongoing, long-term basis. This continuous care is essential for residents who require extended assistance. In contrast, respite centers offer temporary services, providing similar care but for a short-term duration. These short-term services are designed to give family caregivers a break from their daily responsibilities. Choice A is incorrect because both long-term care and respite centers can offer both physical and emotional care, but the key distinction lies in the duration of care provided. Choice B is incorrect as respite centers do not typically offer outpatient services, and the focus is on temporary relief rather than long-term care. Choice D is incorrect as the question clearly highlights a major difference between long-term care and respite centers.
Similar Questions
Access More Features
NCLEX RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access
NCLEX RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access