NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. What term is used to describe the sexual response changes among middle-aged men?
- A. Menopause
- B. Climacteric
- C. Generativity
- D. Maturity
Correct answer: B
Rationale: The correct answer is 'Climacteric.' Climacteric specifically refers to the period in middle-aged men characterized by sexual response changes, such as delayed arousal. Menopause, choice A, is incorrect as it is specific to women and marks the cessation of menstrual periods. Generativity, choice C, is unrelated as it refers to the concern for guiding the next generation. Maturity, choice D, is too broad and generally refers to reaching the adult stage of development, not specifically addressing sexual response changes in middle-aged men.
2. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?
- A. Perform nursing activities throughout the entire shift
- B. Assess for signs of increased muscle tone
- C. Minimize environmental noise
- D. Teach clients to perform the Valsalva maneuver
Correct answer: C
Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.
3. During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?
- A. Constipation
- B. Air-filled areas
- C. Presence of a tumor
- D. Presence of dense organs
Correct answer: B
Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.
4. Which of the following is the correct sequence for removing personal protective equipment?
- A. Remove gown, gloves, shoe covers, mask
- B. Remove mask, gloves, gown, shoe covers
- C. Remove gloves, gown, mask, shoe covers
- D. Remove shoe covers, mask, gloves, gown
Correct answer: C
Rationale: The correct sequence for removing personal protective equipment is crucial to prevent contamination. When exiting a surgical or aseptic situation, the proper sequence is to first remove gloves, followed by the gown, mask, and finally shoe covers. This order ensures that potentially contaminated items are removed first, minimizing the risk of exposure. Choice A, 'Remove gown, gloves, shoe covers, mask,' is incorrect as gloves should be removed before the gown. Choice B, 'Remove mask, gloves, gown, shoe covers,' is incorrect as gloves should be removed first. Choice D, 'Remove shoe covers, mask, gloves, gown,' is incorrect as gloves should be the first item removed to prevent contamination.
5. What is the most effective step in hand washing?
- A. Using friction to remove potential pathogens.
- B. Using hospital-grade soap.
- C. Moisturizing the hands after washing to prevent cracking.
- D. Washing hands with soap for at least 15 seconds.
Correct answer: A
Rationale: The most effective step in hand washing is using friction to remove potential pathogens. While using soap, moisturizing hands, and washing for a sufficient duration are important aspects of hand hygiene, the mechanical action of rubbing hands together with friction is crucial in dislodging and removing dirt, debris, and potential pathogens. Hospital-grade soap may be beneficial, but the physical act of friction is key to effective hand washing. Moisturizing after washing is important for skin health but not the most effective step in the hand washing process. Simply washing hands for a specific duration, such as 15 seconds, without proper friction may not effectively remove contaminants. Therefore, using friction for thorough cleaning is the most crucial step in hand washing.
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