NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. Assuming that an elderly patient will have a difficult time understanding the directions for how to take medication is an example of:
- A. Prejudice
- B. Stereotyping
- C. Encoding
- D. Rationalization
Correct answer: B
Rationale: Stereotyping is defined as providing a generalization about a person based on their culture or characteristics. In this scenario, assuming that an elderly patient will have difficulty understanding medication directions solely based on their age is an act of stereotyping. The healthcare provider is attributing a generalized trait to the patient without considering individual differences. Prejudice, on the other hand, involves forming a negative opinion about someone based on their heritage or culture, which is not evident in this situation. Encoding refers to the process of converting information into a form that can be stored in memory, and rationalization involves justifying one's behavior or decisions with logical reasons, neither of which are applicable in this context.
2. Which of the following constitutes the five rights of medication administration?
- A. Right client, right nurse, right time, right dose, right route
- B. Right client, right time, right dose, right route, right order
- C. Right client, right drug, right dose, right time, right route
- D. Right physician, right nurse, right client, right drug, right dose
Correct answer: C
Rationale: The five rights of medication administration are essential to ensure safe and effective drug delivery to clients. The correct answer includes ensuring the right client receives the right drug at the right dose, via the right route, and at the right time. These elements are crucial to prevent medication errors and ensure optimal therapeutic outcomes. Choice A is incorrect as it includes 'right nurse' which is not part of the five rights of medication administration. Choice B is incorrect as it includes 'right order' which is not part of the five rights. Choice C is incorrect as it includes 'right drug' and 'right route', but it lacks 'right client' and 'right time'. Choice D is incorrect as it includes 'right physician' which is not part of the five rights.
3. During a heritage assessment, which question is most appropriate for the nurse to ask?
- A. "Do you smoke?"?
- B. "What is your religion?"?
- C. "Do you have a history of heart disease?"?
- D. "How many years have you lived in the United States?"?
Correct answer: D
Rationale: During a heritage assessment, it is crucial for the nurse to ask questions related to a person's country of ancestry, years in the United States, cultural practices, beliefs, and values. By asking about the number of years lived in the United States, the nurse can gain insights into the individual's cultural background and heritage. Options B, C, and A are not directly related to assessing heritage. Asking about religion only addresses one aspect of heritage, while smoking history and health history do not provide a comprehensive view of a person's heritage.
4. 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.
5. 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.
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