NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. Working in a clinic located in a community with many Hispanics, what strategy could the nurse implement to decrease health care disparities for Hispanic patients?
- A. Improve public transportation to the clinic.
- B. Update equipment and supplies at the clinic.
- C. Obtain low-cost medications for clinic patients.
- D. Teach clinic staff about Hispanic health beliefs.
Correct answer: D
Rationale: Health care disparities are primarily rooted in stereotyping, biases, and prejudice among healthcare providers. By educating clinic staff about Hispanic health beliefs, the nurse can help combat these issues, leading to improved cultural competency and patient care. Understanding the cultural context of Hispanic patients can enhance communication, trust, and treatment adherence. Improving public transportation, updating equipment, and obtaining low-cost medications are important aspects of healthcare delivery but do not directly address the underlying causes of health disparities experienced by Hispanic patients.
2. A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
- A. External light sources may cause falsely high oximetry values
- B. A bright light in the client's face may cause a low pulse oximetry
- C. External light sources may cause falsely low oximetry values
- D. The client needs a dark and quiet room to recover and maintain proper oxygenation
Correct answer: A
Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.
3. What is involved in obtaining informed consent?
- A. An explanation of the reasons for the procedure
- B. A signature on a form indicating the client agrees to the procedure
- C. A statement affirming liability if complications arise during the procedure
- D. Both A and C
Correct answer: A
Rationale: Informed consent involves providing the client with an explanation of the reasons for the procedure, the potential risks, benefits, and available alternatives. It is essential for the healthcare provider to ensure that the client understands the information provided before agreeing to the procedure. While obtaining a signature on a consent form is part of the process, it is not the sole indicator of informed consent. Option C, which mentions liability statements, is incorrect as informed consent focuses on ensuring the client understands the procedure, not on affirming liability. Therefore, the correct answer is the explanation of the reasons for the procedure.
4. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?
- A. Torticollis, with shortening of the sternocleidomastoid muscle
- B. Craniosynostosis, with premature closure of the cranial sutures
- C. Plagiocephaly, with flattening of one side of the head
- D. Hydrocephalus, with increased head size
Correct answer: A
Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.
5. Which of the following conditions may cause an increased respiratory rate?
- A. Stooped posture
- B. Narcotic analgesics
- C. Injury to the brain stem
- D. Anemia
Correct answer: D
Rationale: Anemia can lead to an increased respiratory rate. In anemia, there are decreased levels of hemoglobin in red blood cells, which are responsible for carrying oxygen to the body's tissues. To compensate for the reduced oxygen-carrying capacity, the body increases the respiratory rate to bring in more oxygen. Stooped posture (Choice A) is not directly related to an increased respiratory rate. Narcotic analgesics (Choice B) are more likely to cause a decreased respiratory rate due to their central nervous system depressant effects. Injury to the brain stem (Choice C) can affect respiratory function but may not necessarily lead to an increased respiratory rate.
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