NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?
- A. Electrical energy fields
- B. Spinal column manipulation
- C. Mind-body balance
- D. Exercise of joints
Correct answer: B
Rationale: The focus of the nurse's response should be on spinal column manipulation when discussing chiropractic treatment for illnesses. Chiropractic theory emphasizes that misalignment of the vertebrae can interfere with the transmission of mental impulses between the brain and body organs, leading to diseases. Manipulation is aimed at reducing such misalignments, known as subluxations. While mind-body balance and exercise of joints are important aspects of holistic health, in the context of chiropractic treatment, the key intervention is spinal column manipulation to address vertebral misalignments. Therefore, choices A, C, and D are incorrect as they do not directly address the primary focus of chiropractic treatment.
2. The client is being educated about depression by the nurse. Which statement by the client indicates that the teaching has been effective?
- A. ''All elderly individuals experience depression occasionally.''
- B. ''I'm relieved that I will improve within 2 or 3 days.''
- C. ''I never realized depression could occur without a specific cause.''
- D. ''Reducing stress in my life will alleviate the depression.''
Correct answer: C
Rationale: The correct answer, 'I never realized depression could occur without a specific cause,' demonstrates an understanding that depression can arise without a clear trigger, indicating effective teaching. Choice A is incorrect because not all elderly individuals experience depression, and this statement doesn't show understanding. Choice B is incorrect as it reflects a misconception about the quick resolution of depression. Choice D is incorrect as it oversimplifies the relationship between stress reduction and depression resolution.
3. A client is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:
- A. Avoid eating red meat for 3 days before the test
- B. Collect the stool sample from the toilet after having a bowel movement
- C. The stool does not need to be kept in a container with preservative
- D. A small part of the stool from two areas will be tested using a smear
Correct answer: B
Rationale: When preparing to give a stool sample for occult blood testing, clients need specific instructions to ensure accurate results. It is crucial to educate clients to avoid eating red meat for at least 3 days before the test, as the blood in the meat can interfere with the test results. Clients should be informed that the stool does not need to be kept in a container with preservative as it is not required for this type of testing. Additionally, clients should be aware that a small part of the stool from two areas will be tested using a smear. However, collecting the stool sample from the toilet after having a bowel movement is not recommended as it may introduce contaminants and affect the accuracy of the test. Therefore, this information is not part of the correct teaching for the client preparing to give a stool sample for occult blood.
4. A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?
- A. Lithotomy position
- B. Prone position
- C. Dorsal recumbent position
- D. High Fowler's position
Correct answer: C
Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.
5. A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:
- A. Evisceration
- B. Hematoma
- C. Dehiscence
- D. Granulation
Correct answer: C
Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.
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