NCLEX-RN
NCLEX RN Exam Preview Answers
1. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo?
- A. Trying prayer before seeking medical help
- B. Believing that illness is a punishment of sin
- C. Refusing to accept blood products as part of treatment
- D. Stating that a child's birth defect is the result of the parents' sins
Correct answer: C
Rationale: The concept of a cultural taboo involves practices that are forbidden or avoided within a particular culture. Refusing to accept blood products as part of treatment is a clear example of a cultural taboo, as some cultures or religions prohibit the use of blood products for medical purposes. This practice is deeply rooted in cultural beliefs and traditions. The other choices provided do not directly relate to cultural taboos. Trying prayer before seeking medical help, believing illness is a punishment of sin, and stating that a child's birth defect is the result of parents' sins are beliefs or actions based on religious or personal beliefs, but they do not specifically represent cultural taboos.
2. The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?
- A. Incomplete data
- B. Generalizing from experience
- C. Identifying with the client
- D. Lack of clinical experience
Correct answer: A
Rationale: In this scenario, the nurse is cautious about potential diagnostic errors due to incomplete data. When a client withholds information, it can lead to incomplete data, which may result in inaccurate nursing diagnoses and care planning. Therefore, the nurse's primary concern is collecting accurate data to make informed clinical decisions. Choices B, C, and D are not relevant to the situation described. Generalizing from experience, identifying with the client, and lack of clinical experience do not directly address the issue of incomplete data impacting the diagnostic process.
3. To collect timely, specific information, the nurse is most likely to ask which of the following questions?
- A. Would you describe what you are feeling?
- B. How are you today?
- C. What would you like to talk about?
- D. Where does it hurt?
Correct answer: A
Rationale: The correct answer is, 'Would you describe what you are feeling?' This open-ended question prompts the patient to provide subjective data, offering specific information about their current health status and human responses. This information can help identify actual or potential health issues. Choices B and C are more likely to yield general, nonspecific information. Choice D may lead to a brief response or nonverbal indication of pain location. A more effective approach to gather specific information about pain would be to ask, 'Can you describe any pain you are experiencing?'
4. When cleansing the genital area during perineal care, the nurse should _____________.
- A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
- B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
- C. cleanse the rectal area first and then clean the patient's genital area.
- D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.
Correct answer: B
Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.
5. Which of the following statements best describes footdrop?
- A. The foot is permanently fixed in the dorsiflexion position
- B. The foot is permanently fixed in the plantar flexion position
- C. The toes of the foot are permanently fanned
- D. The heel of the foot is permanently rotated outward
Correct answer: B
Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.
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