NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.
- A. ask for assistance before getting out of bed.
- B. remain in bed because it is safer and he will not fall.
- C. instruct him to stand up quickly from the bed.
- D. lean forward and push up and off the bed.
Correct answer: A
Rationale: The nurse should encourage Mr. Freeman to use his call bell and ask for assistance before getting out of bed. This can prevent him from falling. Patients should not stay in bed; they should be encouraged to get out of bed as much as possible to prevent complications like pressure ulcers and muscle weakness. Instructing a patient to stand up quickly from the bed is unsafe as it can lead to dizziness and falls. Similarly, leaning forward and pushing off the bed can increase the risk of falls and should be avoided. Asking for assistance is the safest and most appropriate option to ensure patient safety and prevent accidents.
2. According to HIPAA, which of the following is considered an individual right for privacy of a client's protected health information?
- A. The right to receive a copy of the organization's privacy practices
- B. The right to receive medical bills for care received
- C. The right to change personal health information
- D. An understanding that protected health information will only be used in regards to client treatments
Correct answer: A
Rationale: According to HIPAA, individuals receiving care at healthcare facilities have rights surrounding their protected health information. One of these rights is to receive a copy of the organization's privacy practices, which outlines how their health information will be used and protected. This ensures transparency and allows individuals to understand how their information is handled. The other choices are incorrect because while individuals have the right to access their health information, receive explanations of how it is used, and ensure its confidentiality, receiving medical bills or changing personal health information are not specifically outlined as rights related to the privacy of protected health information.
3. A nurse is caring for a client who is post-op day #1 after a total hip replacement. Although the client was alert with a normal affect in the morning, by lunchtime, the nurse notes the client is confused, has slurred speech, and is having trouble with her balance. Her blood glucose level is 48 mg/dl. What is the next action of the nurse?
- A. Contact the physician immediately
- B. Administer a bolus of 50 cc of D20W through the IV
- C. Administer 10 units of regular insulin
- D. Give the client 6 oz. of orange juice
Correct answer: D
Rationale: A client with a blood glucose level of 48 mg/dl is experiencing significant hypoglycemia, as manifested by confusion, balance difficulties, and slurred speech. The nurse should work to correct this situation as rapidly as possible. The first measure that can be performed quickly and will have fast results is to give the client something to eat or drink that contains glucose, such as 6 oz. of orange juice. Administering a bolus of D20W through the IV (Choice B) would be too aggressive and could lead to complications in this scenario. Administering regular insulin (Choice C) would further lower the blood glucose level, worsening the client's symptoms. Contacting the physician (Choice A) is important, but immediate intervention to raise the blood glucose level is crucial to address the client's hypoglycemia.
4. A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?
- A. Lithotomy position
- B. Prone position
- C. Dorsal recumbent position
- D. High Fowler's position
Correct answer: C
Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.
5. Which of the following is an example of restorative care?
- A. A nurse teaches a new mother how to breastfeed her infant
- B. A nurse helps a client with developing a bladder-retraining program
- C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
- D. A nurse contacts the family of a client to tell them he will be out of surgery soon
Correct answer: B
Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.
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