NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse prioritize first on the list to be discharged in order to make a room available for a new admission?
- A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
- B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
- C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
- D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.
Correct answer: A
Rationale: The best candidate for discharge during a need for emergency room availability is a stable patient with a chronic condition who is familiar with their care. In this scenario, the middle-aged client in option A, who has been ventilator dependent for over seven years and admitted with bacterial pneumonia five days ago, is most suitable for discharge. This client is likely stable and can continue medication therapy at home, making them the most appropriate choice for discharge at this time. Choice B should not be the priority for discharge as the young adult with diabetes mellitus Type 2 admitted with antibiotic-induced diarrhea 24 hours ago may need further monitoring and management of their condition. Choice C, the elderly client with multiple comorbidities and admitted with Stevens-Johnson syndrome on the same day, is not a suitable candidate for immediate discharge as they may require ongoing medical attention and observation. Choice D, the adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago, should not be discharged first as acute cellulitis may require continued treatment and monitoring, especially in the context of a positive HIV status.
2. Which of the following is classified as a prerenal condition that affects urinary elimination?
- A. Nephrotoxic medications
- B. Pericardial tamponade
- C. Neurogenic bladder
- D. Polycystic kidney disease
Correct answer: B
Rationale: A prerenal condition is one that causes reduced urinary elimination by affecting the blood flow to the kidneys. Pericardial tamponade is a condition that impacts the heart's ability to pump sufficient blood, leading to decreased blood flow to vital organs such as the kidneys. This reduction in blood flow to the kidneys can result in decreased urine production. The other choices, such as nephrotoxic medications, neurogenic bladder, and polycystic kidney disease, do not primarily affect the blood flow to the kidneys and are not classified as prerenal conditions that impact urinary elimination.
3. In which of these patients would rectal temperatures be measured?
- A. Older adult
- B. Critically ill patient
- C. School-age child
- D. Patient receiving oxygen via nasal cannula
Correct answer: B
Rationale: Rectal temperature measurement is preferred in situations where other routes are impractical or when the most accurate measure is necessary, such as in critically ill patients. The rectal route may be chosen due to its reliability in such cases. For older adults, school-age children, and patients receiving oxygen via nasal cannula, rectal temperature measurement is not typically indicated. Other routes like oral, tympanic, or axillary measurements are more commonly used in these populations due to comfort, convenience, and non-invasive nature.
4. A patient has a goal of eating at least 50% of each meal. The patient refuses to eat, so a nurse force-feeds the patient in order for them to reach their goal of eating at least 50% of the meal. The nurse has committed __________ against this patient.
- A. assault
- B. battery
- C. physical neglect
- D. emotional neglect
Correct answer: B
Rationale: The correct answer is 'battery.' Battery occurs when there is unwanted physical contact or force applied to a person without their consent. In this scenario, force-feeding the patient against their will constitutes battery as the nurse is physically interfering with the patient's body without permission. Assault involves the threat of physical harm, which is not present in the situation described. Physical neglect refers to the failure to provide basic care needs, which is not the case here. Emotional neglect involves the failure to address emotional needs, which is also not applicable in this context.
5. What is the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance, as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well?"? The patient will:
- A. demonstrate improved social skills
- B. express a desire to interact with others
- C. become more independent in decision-making
- D. select and participate in one group activity per day
Correct answer: D
Rationale: The correct outcome for the patient with impaired social interaction related to sociocultural dissonance is to select and participate in one group activity per day. This outcome focuses on increasing social involvement, which aligns with addressing the nursing diagnosis. The patient has already expressed a desire to interact with others, so the goal is to facilitate actual participation in social activities. Becoming more independent in decision-making and demonstrating improved social skills are not directly related to the specific nursing diagnosis provided. Additionally, the outcomes must be measurable, making choices A and C less appropriate as they lack specificity and measurability.
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