NCLEX-RN
NCLEX RN Exam Prep
1. Nursing care plans are _______________?
- A. written by CNAs before they provide care
- B. guidelines of care that all nursing team members use
- C. used by nurses but not by nursing assistants
- D. used by nursing assistants but not by nurses
Correct answer: B
Rationale: Nursing care plans are comprehensive documents created by registered nurses to outline individualized care for patients. These plans serve as guidelines for all members of the nursing team, including nursing assistants, to ensure consistent and quality care. Choice A is incorrect as CNAs typically assist in implementing the care plan rather than creating it. Choice C is incorrect as nursing care plans are utilized by all members of the nursing team, not exclusive to only nurses. Choice D is incorrect as nursing assistants also utilize nursing care plans to provide patient care effectively.
2. The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?
- A. Prone position
- B. Supine with no head elevation
- C. Side-lying with the legs extended
- D. Supine with the head elevated 45 degrees
Correct answer: A
Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site. Therefore, the correct choice is the prone position for this postoperative care scenario.
3. The nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range?
- A. Once a shift
- B. Once an hour
- C. Every 2 hours
- D. Every 4 hours
Correct answer: C
Rationale: Restraints should be removed every 2 hours to prevent complications. Moving the joints through their full range of motion helps prevent muscle shortening and contractures. Massaging the area promotes circulation and reduces the risk of pressure injuries. Removing restraints less frequently could lead to complications like decreased circulation and skin breakdown. Options A, B, and D are incorrect because they do not align with the standard practice of removing restraints every 2 hours to ensure patient safety and well-being.
4. 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.
5. Which of the following is an example of emotional abuse?
- A. A slap to the person's hand
- B. Threatening the person
- C. Ignoring and isolating a person
- D. Leaving a patient soiled for hours
Correct answer: C
Rationale: Emotional abuse involves behaviors that harm an individual's self-worth and emotional well-being. Threatening someone instills fear and causes psychological distress, making it a clear example of emotional abuse. Choices A, C, and D involve physical abuse, neglect, and neglect of care, respectively, rather than emotional abuse. A slap to the person's hand constitutes physical abuse, ignoring and isolating a person is neglectful behavior, and leaving a patient soiled for hours falls under neglect of care.
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