NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. Ruth is a 72-year-old patient who has been upset and crying all morning. When asked why she is upset, she turns toward the wall in silence. What collaborative process may be helpful in caring for this patient?
- A. Speak with the patient care technician
- B. Call the chaplain
- C. Call the social worker
- D. Call the patient's husband
Correct answer: A
Rationale: Collaborating with the patient care technician is an appropriate approach in this scenario. Patient care technicians and nurses' aides often provide direct care to patients, developing a closer relationship with them. Patients may feel more comfortable sharing their feelings with these caregivers compared to other healthcare professionals. In this situation, Ruth's distress appears more emotional than spiritual, making it more suitable to speak with someone directly involved in her care. Calling the chaplain (Choice B) might not directly address Ruth's immediate emotional needs as it could focus more on spiritual support. Involving the social worker (Choice C) could help address underlying emotional or social issues, but speaking with the patient care technician is a more direct and immediate step to assess and provide initial support. Calling the patient's husband (Choice D) may not address Ruth's immediate emotional distress and may not be appropriate without understanding the root cause of her upset.
2. The healthcare professional needs to validate which of the following statements pertaining to an assigned client?
- A. The client has a hard, raised, red lesion on his right hand.
- B. A weight of 185 lbs. is recorded in the chart.
- C. The client reported an infected toe.
- D. The client's blood pressure is 124/70.
Correct answer: C
Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3, and 4. The weight, blood pressure, and physical appearance of a lesion can be objectively verified. However, option C, the client reporting an infected toe, requires the nurse to directly assess the client's toe to confirm the statement. This choice involves subjective data that needs to be validated through direct observation, making it the correct answer. Options A, B, and D provide data that can be measured objectively and verified without the need for further assessment.
3. The chain of infection includes the ________________.
- A. germ, agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host
- B. active natural, active artificial, passive natural, and passive artificial
- C. opportunism, weakness, immunity, and colonization
- D. intrinsic, extrinsic, internal, and external transmission
Correct answer: A
Rationale: The chain, or cycle, of infection includes the germ (microorganism), agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host. This sequence describes how infections are passed from one person to another. Choice B is incorrect because it refers to types of immunity, not components of the chain of infection. Choice C is also incorrect as it lists terms unrelated to the chain of infection. Choice D is incorrect as it describes transmission types, not components of the chain of infection. Understanding the chain of infection is crucial in preventing the spread of infections by breaking one or more links in the chain, such as interrupting the mode of transmission through proper hand hygiene.
4. Research participants are involved in a trial that incidentally separates them into two groups. One group receives an intervention, while the other group does not. Both groups are compared for outcomes. What type of research method is this?
- A. Experimental design
- B. Double-blind experiment
- C. Randomized controlled trial
- D. Repeated measures design
Correct answer: C
Rationale: A randomized controlled trial is a research method in which participants are randomly assigned to either a treatment or control group. This design helps eliminate bias and allows for the comparison of outcomes between the two groups. In this scenario, where participants are separated into intervention and non-intervention groups for comparison, it aligns with the characteristics of a randomized controlled trial. The key feature distinguishing it from the other options is the random assignment of participants to groups, ensuring that both groups are comparable at the start of the study. Double-blind experiments involve blinding both participants and researchers to treatment allocation, which is not explicitly mentioned in the scenario. Experimental design refers to a broader category that includes various types of research designs beyond just randomized controlled trials. Repeated measures design involves collecting multiple observations from the same participants over time, which is not the case described in the scenario.
5. Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?
- A. A 65-year old male with urine output of 60cc in the past four hours
- B. A 2-month old female with a temperature of 100.6 rectally
- C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
- D. A 4-year old male with an oxygen saturation of 96% on room air
Correct answer: D
Rationale: Clients must meet a certain amount of set criteria before they will be discharged from a healthcare facility. Although guidelines may vary between locations, most healthcare facilities expect clients to have adequate oxygenation, nutrition, and elimination; and be free from fever, vomiting, and significant pain
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