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. You are working the 8 am to 4 pm shift. You begin to vomit at 3 pm and you do not think that you are able to continue working. You decide to immediately go home without notifying your RN supervisor. You have ________________.
- A. enough sick time, so this is not a problem.
- B. finished all your work, so this is not a problem.
- C. seriously abandoned the patients.
- D. seriously abused and neglected the patients.
Correct answer: D
Rationale: Patient abandonment is a serious violation that can lead to disciplinary action and immediate termination of employment. It is defined as leaving patients without proper consent from the supervisor. In this scenario, leaving work without notifying the RN supervisor and potentially leaving patients unattended is considered patient abandonment, as it compromises patient safety and care. Choices A and B are incorrect because having sick time or finishing work does not justify leaving without proper protocol. Choice D is incorrect as the scenario does not indicate abuse or neglect towards the patients.
3. The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child likely have?
- A. Acromegaly
- B. Marfan syndrome
- C. Hypopituitary dwarfism
- D. Achondroplastic dwarfism
Correct answer: C
Rationale: Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The child's appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood which causes overgrowth of bone in the face, head, hands, and feet.
4. 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.
5. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?
- A. From the tip of the nose to the xiphoid process
- B. From the tip of the nose to the earlobe to the xiphoid process
- C. From the earlobe to the xiphoid process
- D. From the tip of the nose to the earlobe to the umbilicus
Correct answer: B
Rationale: When preparing to insert a nasogastric tube, the nurse must measure the correct length to ensure that the end of the tube will be in the correct position in the stomach. The accurate method to measure the length is from the tip of the nose to the earlobe to the xiphoid process. This length ensures that the end of the tube reaches the stomach, avoiding placement in the small intestine or esophagus. Choice A is incorrect as it does not include the earlobe, which is essential for accurate measurement. Choice C is incorrect because measuring from the earlobe alone does not provide the correct length for positioning in the stomach. Choice D is incorrect as it includes the umbilicus, which is not the appropriate landmark for measuring the length of a nasogastric tube intended for stomach placement.
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