NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. Which body plane divides the body into right and left sides?
- A. Frontal Plane
- B. Medial Plane
- C. Median Plane
- D. Transverse Plane
Correct answer: C
Rationale: The correct answer is the Median Plane, also known as the sagittal plane. It divides the body into right and left sides. The Frontal Plane, or coronal plane, divides the body into front and back sections. The Transverse Plane divides the body into superior (upper) and inferior (lower) sections. Therefore, choices A, B, and D are incorrect as they do not specifically divide the body into right and left sides.
2. What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?
- A. Will comply with the treatment prescribed.
- B. Has given up her belief in naturalistic causes of disease.
- C. May also be seeking the assistance of a shaman or medicine man.
- D. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.
Correct answer: C
Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.
3. Mr. and Mrs. K have just adopted a newborn infant and are preparing to take him home from the hospital for the first time. Which safety measure is most appropriate for the clients in this situation?
- A. Turn the handles of pans on the stove inward
- B. Set up a baby gate at the top of the stairs
- C. Cover electrical outlets with child-proof plugs
- D. Install an approved car seat that is facing backward in the back seat
Correct answer: D
Rationale: Parents of newborn infants should use an approved car seat that has been installed facing backward in the back seat of the car. Securing infants in car seats, even from the first ride home from the hospital, promotes safety while transporting. While safety measures at home such as baby gates or outlet covers are important, they are not the priority safety measures until the baby is old enough to be mobile. The car seat is crucial for protecting the newborn during transportation, ensuring proper positioning and restraint in the event of sudden stops or accidents. Turning handles of pans on the stove inward, setting up a baby gate, and covering electrical outlets are important safety measures at home but are not as critical for the immediate safety of a newborn during transportation.
4. During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?
- A. Fingertips
- B. Dorsal surface of the hand
- C. Ulnar portion of the hand
- D. Palmar surface of the hand
Correct answer: B
Rationale: The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.
5. Which of these is a correctly stated outcome goal written by the nurse?
- A. The client will walk 2 miles daily by March 19
- B. The client will understand how to give insulin by discharge
- C. The client will regain their former state of health by April 1
- D. The client achieve desired mobility by May 7
Correct answer: A
Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option A is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19). Option B lacks specificity in terms of what 'understand how to give insulin' entails, and the timeline is vague ('by discharge'). Option C is not measurable or specific about what 'regain their former state of health' means. Option D does not provide a specific behavior or measurable criteria for 'desired mobility,' and the timeline is the only element that is time-bound.
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