NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. The most accurate reading for a temperature is done:
- A. Orally
- B. Aurally through a clean canal
- C. Rectally
- D. Axially
Correct answer: B
Rationale: Aural readings are done through the ear canal. The tympanic membrane shares a blood supply with the hypothalamus, the brain area that regulates body temperature. Taking the temperature aurally through a clean canal ensures an accurate reading. Choice A (Orally) is not the most accurate method for temperature measurement as it can be affected by external factors like drinking hot or cold liquids. Choice C (Rectally) is invasive and less practical for routine temperature monitoring. Choice D (Axially) is not a standard method for temperature measurement and may not provide accurate results.
2. A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?
- A. Perform mental health assessment interviews
- B. Establish therapeutic relationships
- C. Prescribe psychotropic medications
- D. Individualize nursing care plans
Correct answer: C
Rationale: Prescriptive privileges are granted to Master's-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. In this scenario, the new staff nurse would ask the advanced practice nurse to prescribe psychotropic medications, as this is within their scope of practice and expertise. Establishing therapeutic relationships, performing mental health assessments, and individualizing care plans are typically responsibilities of staff nurses at the basic level, not advanced practice nurses.
3. What does an individual who believes in the magicoreligious theory of illness and disease think is the cause of illness?
- A. Germs and viruses
- B. Supernatural forces
- C. Eating imbalanced (hot/cold) foods
- D. Imbalance within his or her spiritual nature
Correct answer: B
Rationale: Individuals who adhere to the magicoreligious theory of illness and disease attribute the cause of illness to supernatural forces. In this perspective, the world is perceived as governed by supernatural forces that influence the well-being of individuals. The belief is that these forces can bring about both good and evil outcomes. Choices A, C, and D are incorrect. Germs and viruses are associated with the biomedical theory of illness. Eating imbalanced hot or cold foods is linked to the yin/yang naturalist theory. Imbalance within one's spiritual nature is not a recognized cause of illness in any of the established theories of illness.
4. Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.
- A. Client and Family
- B. Other nursing staff on the unit
- C. Security department
- D. Hospital administration
Correct answer: B
Rationale: Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.
5. When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
- A. Securely grasp the client's arm and leg.
- B. Put bed rails up on the side of bed opposite from the nurse.
- C. Correctly position and use a turn sheet.
- D. Lower the head of the client's bed slowly
Correct answer: B
Rationale: When turning an immobile bedridden client without assistance, the best action to ensure client safety is to put bed rails up on the side of the bed opposite from the nurse. This is important because the nurse can only stand on one side of the bed, so having bed rails on the opposite side prevents the client from falling out of bed. Option A, which suggests securely grasping the client's arm and leg, can potentially cause client injury to the skin or joints. Options C and D, correctly positioning and using a turn sheet, and lowering the head of the client's bed slowly, respectively, are useful techniques during client turning but are of lower priority in terms of safety compared to the use of bed rails.
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