NCLEX-RN
NCLEX RN Exam Prep
1. Which of the following is classified as a prerenal condition that affects urinary elimination?
- A. Nephrotoxic medications
- B. Pericardial tamponade
- C. Neurogenic bladder
- D. Polycystic kidney disease
Correct answer: B
Rationale: A prerenal condition is one that causes reduced urinary elimination by affecting the blood flow to the kidneys. Pericardial tamponade is a condition that impacts the heart's ability to pump sufficient blood, leading to decreased blood flow to vital organs such as the kidneys. This reduction in blood flow to the kidneys can result in decreased urine production. The other choices, such as nephrotoxic medications, neurogenic bladder, and polycystic kidney disease, do not primarily affect the blood flow to the kidneys and are not classified as prerenal conditions that impact urinary elimination.
2. Assuming that an elderly patient will have a difficult time understanding the directions for how to take medication is an example of:
- A. Prejudice
- B. Stereotyping
- C. Encoding
- D. Rationalization
Correct answer: B
Rationale: Stereotyping is defined as providing a generalization about a person based on their culture or characteristics. In this scenario, assuming that an elderly patient will have difficulty understanding medication directions solely based on their age is an act of stereotyping. The healthcare provider is attributing a generalized trait to the patient without considering individual differences. Prejudice, on the other hand, involves forming a negative opinion about someone based on their heritage or culture, which is not evident in this situation. Encoding refers to the process of converting information into a form that can be stored in memory, and rationalization involves justifying one's behavior or decisions with logical reasons, neither of which are applicable in this context.
3. The nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range?
- A. Once a shift
- B. Once an hour
- C. Every 2 hours
- D. Every 4 hours
Correct answer: C
Rationale: Restraints should be removed every 2 hours to prevent complications. Moving the joints through their full range of motion helps prevent muscle shortening and contractures. Massaging the area promotes circulation and reduces the risk of pressure injuries. Removing restraints less frequently could lead to complications like decreased circulation and skin breakdown. Options A, B, and D are incorrect because they do not align with the standard practice of removing restraints every 2 hours to ensure patient safety and well-being.
4. The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?
- A. Incomplete data
- B. Generalizing from experience
- C. Identifying with the client
- D. Lack of clinical experience
Correct answer: A
Rationale: In this scenario, the nurse is cautious about potential diagnostic errors due to incomplete data. When a client withholds information, it can lead to incomplete data, which may result in inaccurate nursing diagnoses and care planning. Therefore, the nurse's primary concern is collecting accurate data to make informed clinical decisions. Choices B, C, and D are not relevant to the situation described. Generalizing from experience, identifying with the client, and lack of clinical experience do not directly address the issue of incomplete data impacting the diagnostic process.
5. Specific gravity in urinalysis:
- A. compares the concentration of urine to that of distilled water
- B. is useless when the patient is dehydrated
- C. can only be measured using a refractometer
- D. None of the above
Correct answer: A
Rationale: Specific gravity in urinalysis measures the concentration of solutes in urine compared to that of distilled water. This comparison helps in assessing the kidney's ability to concentrate urine properly. It is a valuable test even in dehydrated patients as it provides insights into renal function. Specific gravity can be measured using various methods, including a refractometer or reagent strips. Normal specific gravity readings of human urine typically range from 1.005 to 1.030. Choice A is correct as it accurately describes the purpose of specific gravity in urinalysis. Choices B and C are incorrect as specific gravity remains relevant in dehydrated patients and can be measured using different techniques, not solely a refractometer.
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