NCLEX-RN
NCLEX RN Exam Prep
1. The nurse should wash from the ________________________ when washing a patient's eye area.
- A. outer canthus to the inner canthus
- B. inner canthus to the outer canthus
- C. internal nares to the external nares
- D. external nares to the internal nares
Correct answer: B
Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.
2. When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?
- A. When the infant is sleeping
- B. At the end of the examination
- C. Before auscultation of the thorax
- D. At about the middle of the examination
Correct answer: B
Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.
3. When considering the structural organization of the human body, what is the basic unit of life?
- A. Chemicals
- B. Atoms
- C. Molecules
- D. Cells
Correct answer: D
Rationale: The basic unit of life is the cell. Cells are considered the fundamental unit of life because they are capable of carrying out all the processes necessary for life, such as growth, reproduction, responding to stimuli, and more. While chemicals, atoms, and molecules are essential components of cells and living organisms, they are not considered the basic unit of life. Chemicals are general substances, atoms are the smallest units of matter, and molecules are combinations of atoms. Therefore, the correct answer is cells, as they are the building blocks of all living organisms.
4. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?
- A. Assist the client in using the bathroom one hour after going to bed
- B. Give the client a massage before bedtime
- C. Tuck bed sheets and blankets tightly around the client once settled in bed
- D. Give the client a pair of socks to wear if their feet become cold
Correct answer: D
Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.
5. Which of the following constitutes the five rights of medication administration?
- A. Right client, right nurse, right time, right dose, right route
- B. Right client, right time, right dose, right route, right order
- C. Right client, right drug, right dose, right time, right route
- D. Right physician, right nurse, right client, right drug, right dose
Correct answer: C
Rationale: The five rights of medication administration are essential to ensure safe and effective drug delivery to clients. The correct answer includes ensuring the right client receives the right drug at the right dose, via the right route, and at the right time. These elements are crucial to prevent medication errors and ensure optimal therapeutic outcomes. Choice A is incorrect as it includes 'right nurse' which is not part of the five rights of medication administration. Choice B is incorrect as it includes 'right order' which is not part of the five rights. Choice C is incorrect as it includes 'right drug' and 'right route', but it lacks 'right client' and 'right time'. Choice D is incorrect as it includes 'right physician' which is not part of the five rights.
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