NCLEX NCLEX-RN
NCLEX RN Exam Review Answers
1. Based on Mr. C's assessment, which of the following nursing interventions is most appropriate?
- A. Elevate the lower extremities to 45 degrees to promote venous return
- B. Place Mr. C in the Trendelenburg position
- C. Administer total parenteral nutrition
- D. Monitor urine output
Correct answer: Monitor urine output
Rationale: In the context of Mr. C's assessment, the most appropriate nursing intervention is to monitor urine output. A client in hypovolemic shock may experience decreased urine output due to poor kidney perfusion. By monitoring urine output, the nurse can assess renal function and fluid status. Administering total parenteral nutrition (Choice C) is not indicated based on the information provided, as the priority is to stabilize the client's condition. Elevating the lower extremities (Choice A) may be helpful in some cases but is not the priority in this situation. Placing Mr. C in the Trendelenburg position (Choice B) is contraindicated in hypovolemic shock as it can worsen venous return and compromise cardiac output.
2. Which of the following types of dressing changes works as a form of wound debridement?
- A. Dry dressing
- B. Transparent dressing
- C. Composite dressing
- D. Wet to dry dressing
Correct answer: Wet to dry dressing
Rationale: The correct answer is 'Wet to dry dressing.' Wet to dry dressing is a method of wound debridement that involves applying sterile soaked gauze to the wound, allowing it to dry and stick to the wound. When the dressing is removed, it pulls away drainage and debris, aiding in wound debridement. Choice A, 'Dry dressing,' does not actively assist in debridement as it does not collect or remove debris from the wound. Choice B, 'Transparent dressing,' is primarily used for maintaining a moist environment and wound observation, not for debridement. Choice C, 'Composite dressing,' combines multiple layers for different wound care purposes but is not specifically designed for debridement like wet to dry dressing.
3. Which of the following sets of word parts means 'Pain'?
- A. dynia and -algia
- B. a- and an
- C. ia and -ac
- D. pathy and -osis
Correct answer: dynia and -algia
Rationale: The correct answer is 'dynia and -algia.' The word parts 'dynia' and '-algia' specifically relate to pain. 'Dynia' refers to pain, and '-algia' also denotes pain. Therefore, when combined, they form the meaning 'pain.' Choices B, C, and D are incorrect because 'a-' and 'an' do not relate to pain, 'ia' and '-ac' do not specifically convey pain, and 'pathy' and '-osis' are not word parts that directly signify pain.
4. Albert is a patient in the hospital who is scheduled for surgery the following morning. After the pre-operative visit from the anesthesia staff member who has obtained surgical consent, Albert asks for an explanation of what type of surgery he is going to have. He states that he's not sure what he just signed. What is your best response?
- A. Don't worry, they'll explain it in the operating room.
- B. It's standard procedure to get the consent; you don't need to worry.
- C. Let me ask the nurse anesthetist to come back and explain it further.
- D. Someone will review it with you prior to surgery.
Correct answer: Let me ask the nurse anesthetist to come back and explain it further.
Rationale: The correct response is to ensure that the patient fully understands the nature of the surgery they are about to undergo. If the patient expresses uncertainty about the procedure they signed consent for, it indicates a lack of informed consent, which is essential before any surgery. By requesting the nurse anesthetist to return and provide a more detailed explanation, the patient can make an informed decision. Choices A, B, and D do not address the issue of the patient's lack of understanding and the need for informed consent, making them incorrect. Option C is the best course of action to rectify the situation and ensure the patient's understanding and consent are properly obtained.
5. Jack is a 2-month-old with a diagnosis of spinal muscular atrophy (SMA) type I. He has been admitted to the hospital for progressive respiratory difficulty. His parents have been informed that if he is not placed on ventilatory support, he will continue to decompensate and die of respiratory failure. Jack's physician discusses the poor prognosis of Jack's condition, and tells the parents that he will not be able to be removed from ventilatory support once it is initiated, due to his progressive neurological disease. After much discussion, the parents have decided to decline ventilatory support, agree to a do not resuscitate (DNR) order, and request hospice care for Jack. Another parent heard them discussing Jack's situation in the waiting room and says she could never do that to her baby. What is the most appropriate response to this parent?
- A. You never know what you'll do until you're in that situation.
- B. I can't discuss another patient's situation.
- C. They have been through too much already.
- D. You can contact administration with your concerns.
Correct answer: I can't discuss another patient's situation.
Rationale: In healthcare settings, privacy regulations prevent professionals from discussing patient situations with individuals not involved in that patient's care. Maintaining patient confidentiality is crucial to protect sensitive information. In this scenario, sharing details about Jack's situation with the parent who overheard the conversation would breach confidentiality. It is important to handle such situations delicately, especially in emotional environments like intensive care unit waiting rooms. While empathy and support are essential, it is equally crucial to respect patient privacy and confidentiality. Therefore, responding with 'I can't discuss another patient's situation' is the most appropriate and professional response in this context.
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