NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?
- A. A little, a moderate amount, or all of the meal
- B. 50 cc, 100 cc, or 500 cc of the meal
- C. 25%, 50%, or 100% of the meal
- D. Either A or C
Correct answer: C
Rationale: Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate. Choices A and B are incorrect. Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation. Choice B's use of cc is more appropriate for measuring fluids, not solid foods. Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.
2. The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or healthcare providers, the nurse emphasizes interventions that do which of the following? (Berman & Snyder, 2012, p. 713)
- A. Eliminate the reservoir
- B. Block the portal of exit from the reservoir
- C. Block the portal of entry into the host
- D. Decrease the susceptibility of the host
Correct answer: B
Rationale: To prevent the spread of infection from a chronic carrier, the nurse should focus on blocking the portal of exit from the reservoir, which is the carrier person. By preventing the movement of the organism from the reservoir, the infection can be contained. Eliminating the reservoir is not feasible in this case as the carrier is a chronic carrier. Blocking the portal of entry into the host or decreasing the susceptibility of the host would only impact individual prevention and not the spread from the carrier to others.
3. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?
- A. Collaborating with the client to establish healthcare goals
- B. Reviewing the client's medical record history
- C. Explaining the purpose of administered medications to the client
- D. Rapidly resetting priorities for client care based on changes in the client's condition
Correct answer: D
Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.
4. Why should direct care providers avoid glued-on artificial nails?
- A. Interfere with dexterity of the fingers.
- B. Could fall off in a patient's bed.
- C. Harbor microorganisms.
- D. Can scratch a patient.
Correct answer: C
Rationale: Direct care providers, including nurses, should avoid glued-on artificial nails because studies have shown that artificial nails, especially when cracked, broken, or split, create crevices where microorganisms can thrive and multiply. This can lead to an increased risk of transmitting infections to patients. Therefore, the primary reason for avoiding glued-on artificial nails is their potential to harbor harmful microorganisms, making option C the correct choice. Options A, B, and D are incorrect because while they may present some issues, the primary concern is the risk of microbial contamination associated with artificial nails.
5. A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?
- A. Perform mental health assessment interviews
- B. Establish therapeutic relationships
- C. Prescribe psychotropic medications
- D. Individualize nursing care plans
Correct answer: C
Rationale: Prescriptive privileges are granted to Master's-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. In this scenario, the new staff nurse would ask the advanced practice nurse to prescribe psychotropic medications, as this is within their scope of practice and expertise. Establishing therapeutic relationships, performing mental health assessments, and individualizing care plans are typically responsibilities of staff nurses at the basic level, not advanced practice nurses.
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