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 client with multiple sclerosis is being educated by the nurse on exercises and physical activities. Which statement by the client indicates a need for further teaching?
- A. "I can lift weights and engage in resistance training."?
- B. "I should exercise until I am exhausted."?
- C. "I can incorporate aerobic exercises into my routine."?
- D. "I should perform proper stretching before starting my routine."?
Correct answer: B
Rationale: The correct answer is, "I should exercise until I am exhausted."? This statement indicates a need for further teaching because patients with multiple sclerosis should avoid exercising to the point of exhaustion or fatigue. Strenuous physical activity can increase body temperature and potentially worsen symptoms in individuals with multiple sclerosis. Choice A is correct because lifting weights and resistance training can be appropriate exercises for patients with multiple sclerosis. Choice C is valid because aerobic exercises can also be beneficial. Choice D is accurate as proper stretching before starting an exercise routine is essential for preventing injuries.
3. Mary T. was admitted to a nursing home on May 1st. On July 4th, she was diagnosed with a skin infection. This infection is considered a ________________ infection.
- A. nosocomial
- B. systemic
- C. resident flora
- D. resident aura
Correct answer: A
Rationale: The correct answer is 'nosocomial.' A nosocomial infection is defined as one that is not present upon admission to a healthcare facility but instead occurs during the patient's stay. In this case, since Mary was diagnosed with a skin infection after being admitted to the nursing home, it is considered a nosocomial infection. Nosocomial infections are a significant concern in healthcare settings, and infection control measures are in place to prevent their spread. Choices B, C, and D are incorrect. 'Systemic' refers to a condition affecting the entire body, not specific to a healthcare setting. 'Resident flora' and 'resident aura' are not commonly used terms in healthcare and do not relate to infections acquired in healthcare facilities.
4. After a lengthy explanation of a medical procedure, the patient asks many questions. The physician answers all of the questions to the best of their ability. The patient then gives consent for treatment. The costly equipment and supplies are put into place, and the patient is prepared. Two minutes before the procedure is to start, the patient begins panicking and changes their mind. Which of the following situations would be the best way to avoid litigation?
- A. Document that the patient originally gave consent and proceed if the benefits of the procedure outweigh the patient's wishes.
- B. Have the patient sign a form stating that they are refusing consent. If they refuse to sign, do not proceed with the procedure.
- C. Repeat the explanation of the procedure until the patient understands that having the procedure done is the best form of treatment. Do not proceed with the procedure.
- D. Do not proceed. Document the patient's refusal, have the patient sign a refusal to consent to treatment. If the patient refuses to sign the form, have a witness available to sign.
Correct answer: D
Rationale: In this scenario, the best course of action to avoid litigation is to respect the patient's right to refuse treatment, especially when changing their mind before the procedure starts. By not proceeding with the treatment, documenting the patient's refusal, and having the patient sign a refusal to consent form, you are following proper ethical and legal procedures. If the patient refuses to sign the form, having a witness available to sign further strengthens the documentation of the patient's decision. This approach ensures that the patient's autonomy and right to make informed decisions about their healthcare are respected. Choices A, B, and C do not prioritize the patient's right to refuse treatment and could potentially lead to legal issues if treatment is carried out against the patient's wishes.
5. What question must the nurse ask when formulating a nursing diagnosis?
- A. What diagnosis did the physician make for this client?
- B. What is the issue that I can solve for this client?
- C. What physician orders will resolve this issue?
- D. What underlying disease does this client have?
Correct answer: B
Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.
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