NCLEX-RN
NCLEX RN Exam Preview Answers
1. The nurse is reviewing concepts related to one's heritage and beliefs. Which concept refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe?
- A. Culture
- B. Religion
- C. Ethnicity
- D. Spirituality
Correct answer: B
Rationale: Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services. Religion is a shared experience of spirituality or the values, beliefs, and practices into which people are either born or that they may adopt to meet their personal spiritual needs through communal actions, such as religious affiliation, attendance and participation in a religious institution, prayer, or meditation, and religious practices. Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It does not refer to a belief in a divine or superhuman power. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others. Spirituality is a broad term focused on a connection with something bigger than oneself and a belief in transcendence.
2. A healthcare professional is employed at a district health department and must spend several hours each day sitting at a desk. Which principle of ergonomics will most likely help them to reduce the risk of injury or pain in this situation?
- A. Adjust the chair height to keep the legs bent at the hips at a 90-degree angle
- B. Maintain the position of the computer monitor just below eye level
- C. Stand up and take a walk or stretch every 4 hours
- D. Rest wrists on the edge of the desk while typing
Correct answer: A
Rationale: When sitting for prolonged periods, it is important to adjust the height of the chair so that the legs are bent at the hips at a 90-degree angle. This position helps to reduce pressure on the back, legs, and feet, promoting better posture and reducing muscle fatigue. Standing up and moving around at least once every hour is crucial to support circulation and prevent stiffness. Maintaining the position of the computer monitor just below eye level helps reduce strain on the neck and eyes. Resting wrists on the edge of the desk while typing can lead to wrist strain and discomfort, so it is not an ergonomic recommendation for prolonged desk work.
3. A client is being assisted with ambulation in the hallway using a gait belt when they become dizzy and start to faint. What is the first action the nurse should take?
- A. Stand behind the client and prepare to catch them if they fall
- B. Assist the client to sit in the nearest chair or slide down along a wall
- C. Grasp the client under the arms and pull them upward
- D. Call for help from nearby staff
Correct answer: A
Rationale: If a client becomes dizzy and starts to faint while being assisted with ambulation, the nurse's first action should be to assist the client into a sitting position to prevent or reduce the impact of a fall. This can be done by guiding the client to sit in the nearest chair or sliding down along a wall for support. Option A is incorrect because standing behind the client may not prevent a fall and could potentially lead to injury. Option C is incorrect as pulling the client upward may worsen the situation. Option D, calling for help, is not the first action to take when the client is at risk of falling.
4. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client?
- A. Loosen pressure dressings on wounds
- B. Use assistance to lift a client in bed
- C. Check temperature of water used in a sponge bath
- D. Position the client in a prone position
Correct answer: C
Rationale: To reduce environmental stimuli that may cause discomfort for a client, nurses can implement various interventions. Checking the temperature of the water used in a sponge bath is crucial to prevent burns from water that is too hot or discomfort from water that is too cold. This intervention addresses a common source of discomfort for clients during personal care. Loosening pressure dressings on wounds, although important for wound care, does not directly address environmental stimuli. Using assistance to lift a client in bed is about proper positioning and preventing injury rather than reducing environmental stimuli. Positioning the client prone is not a suitable intervention for reducing discomfort caused by environmental stimuli.
5. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to
- A. choose low-fat foods from the menu
- B. perform leg exercises hourly while awake
- C. ambulate the evening of the operative day
- D. turn, cough, and deep breathe every 2 hours
Correct answer: D
Rationale: Postoperative nursing care after a cholecystectomy focuses on preventing respiratory complications due to the surgical incision being high in the abdomen, which impairs coughing and deep breathing. Turning, coughing, and deep breathing every 2 hours help prevent respiratory complications, such as pneumonia. While choices A, B, and C are also important aspects of postoperative care, they are not as high a priority as ensuring proper ventilation and respiratory function in the immediate postoperative period.
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