NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Which principle of body mechanics may help to reduce the risk of a back injury?
- A. Maintain a wide base of support
- B. Bend from the knees, not the waist
- C. Keep the back straight while lifting
- D. Push or pull objects rather than lifting
Correct answer: C
Rationale: Proper body mechanics are crucial to prevent injuries, especially for professions involving lifting and moving objects. Keeping the back straight while lifting is essential to reduce the risk of back injuries as it helps maintain the spine's natural alignment and prevents excessive strain on the back muscles. Choosing choices A, B, and D would increase the risk of back injury. Maintaining a wide base of support provides stability, bending from the knees instead of the waist protects the lower back, and pushing or pulling objects reduces the strain on the back muscles, all contributing to preventing back injuries.
2. An Asian-American woman is experiencing diarrhea, which is believed to be "cold"? or "yin."? What should the nurse recognize that the woman may likely try to treat it?
- A. Foods that are "hot"? or "yang"?
- B. Readings and Eastern medicine meditations
- C. High doses of medicines believed to be "cold"?
- D. No treatment because diarrhea is an expected part of life.
Correct answer: A
Rationale: In this scenario, the Asian-American woman is believed to be experiencing diarrhea due to a "cold"? or "yin"? imbalance. According to the yin/yang theory, yang represents heat and yin represents cold. Therefore, to balance the cold nature of the diarrhea, the woman may try to treat it by consuming foods that are considered "hot"? or "yang"?. This aligns with the concept that cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. Choices B, C, and D do not align with the yin/yang theory and are not relevant to addressing the imbalance associated with the cold nature of the diarrhea.
3. A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to
- A. choose low-fat foods from the menu
- B. perform leg exercises hourly while awake
- C. ambulate the evening of the operative day
- D. turn, cough, and deep breathe every 2 hours
Correct answer: D
Rationale: Postoperative nursing care after a cholecystectomy focuses on preventing respiratory complications due to the surgical incision being high in the abdomen, which impairs coughing and deep breathing. Turning, coughing, and deep breathing every 2 hours help prevent respiratory complications, such as pneumonia. While choices A, B, and C are also important aspects of postoperative care, they are not as high a priority as ensuring proper ventilation and respiratory function in the immediate postoperative period.
4. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?
- A. Client will be able to turn self by day 3
- B. Skin will remain intact and without redness during hospital stay
- C. Client will state pain relieved within 30 minutes after medication
- D. Pressure will be prevented by repositioning client every 2 hours
Correct answer: B
Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.
5. During an assessment, a nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?"? Which aspect of the mental status examination is the nurse assessing?
- A. Behavior
- B. Cognition
- C. Affect and mood
- D. Perceptual disturbances
Correct answer: B
Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.
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