NCLEX-RN
NCLEX RN Exam Review Answers
1. You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?
- A. The infant had doubled their birth weight at twelve months.
- B. The infant had tripled their birth weight at twelve months.
- C. The mother reports that the infant is drinking 60 mLs per kilogram of its body weight.
- D. The infant had grown � inch since last month.
Correct answer: A
Rationale: The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age. The mother's reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown � inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight. As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.
2. A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?
- A. Do you mean your boyfriend?
- B. Do you mean your boyfriend?
- C. No one will ever hurt you again.
- D. Tell me more about what happens when he gets angry.
Correct answer: D
Rationale: The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.
3. Which technological advance is MOST likely to place you at risk for HIPAA violations?
- A. Social media
- B. Word processing programs
- C. Spreadsheets
- D. Cloud storage services (Clouds and SOEs)
Correct answer: A
Rationale: The correct answer is Social media. Social media platforms such as Facebook can significantly put you at risk for HIPAA violations. It is crucial to never share any patient-related information or comments on social media websites, as this breaches patient confidentiality and violates HIPAA regulations. Choices B, C, and D are less likely to directly lead to HIPAA violations. Word processing programs and spreadsheets are commonly used for documentation and data organization, focusing more on internal operations and not on external sharing of sensitive information that can compromise patient confidentiality. Cloud storage services (Clouds and SOEs) are designed for secure data storage and sharing within regulated environments, and HIPAA compliance can be maintained if used appropriately. However, social media's open and unsecured nature makes it a higher risk for HIPAA violations compared to the other technological advances mentioned.
4. A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response?
- A. Patients sleep better with the lights dimmed.
- B. The nightshift nurses prefer to work with less light.
- C. It's time for him to sleep, and you should, too.
- D. There's a reason we do that. Let me share a research study with you.
Correct answer: D
Rationale: The most objective response in this situation is to explain to the family member that there is a specific reason for dimming the lights and offer to share a research study to provide evidence-based information. By doing so, it helps the family member understand that the care provided is based on established practices and research, potentially alleviating her concerns and ensuring that her husband receives appropriate care. Choices A, B, and C do not address the family member's concern or provide a rationale backed by evidence, making them less suitable responses in this context.
5. A 58-year-old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?
- A. 5 mm/hr
- B. 12 mm/hr
- C. 28 mm/hr
- D. 40 mm/hr
Correct answer: D
Rationale: The erythrocyte sedimentation rate (ESR) measures levels of inflammation in the body. Elevated ESR levels are commonly seen in autoimmune conditions like rheumatoid arthritis due to the presence of inflammation. In women over 50 years old, a normal ESR is typically below 30 mm/hr. Therefore, a result of 40 mm/hr is more indicative of arthritis in a 58-year-old individual. Choices A, B, and C are below the normal ESR range for a woman of this age and would not be as strongly associated with arthritis.
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