NCLEX-RN
NCLEX RN Exam Review Answers
1. Which of the following is an example of restorative care?
- A. A nurse teaches a new mother how to breastfeed her infant
- B. A nurse helps a client with developing a bladder-retraining program
- C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
- D. A nurse contacts the family of a client to tell them he will be out of surgery soon
Correct answer: B
Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.
2. Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for:
- A. Rest, Ice, Compression, Elevation
- B. Radiology, Ice, Compression, Elevation
- C. Rest, Ice, Cast, Elevation
- D. Radiology, Ice, Cast, Elevation
Correct answer: A
Rationale: The correct answer is Rest, Ice, Compression, Elevation. This acronym, RICE, is commonly used for the treatment of injuries like an ankle sprain. Rest allows the injured area to heal, Ice helps reduce swelling and pain (20 minutes on each hour while awake), Compression is usually achieved with an elastic bandage to minimize swelling, and Elevation of the foot above the level of the heart assists in reducing swelling and promoting healing. Choices B, C, and D are incorrect because they include irrelevant terms like Radiology and Cast, which are not part of the standard treatment protocol for an ankle sprain.
3. The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?
- A. A 26-year-old woman who had a bowel resection
- B. A 40-year-old man who underwent a hernia repair
- C. A 31-year-old woman with septicemia and who is on a ventilator
- D. A 91-year-old man with Alzheimer's disease recovering from a fall
Correct answer: A
Rationale: When deciding on transferring patients between units in a hospital, it is essential to consider the appropriateness of the patient for the receiving unit. The Women's Health Center typically caters to female patients with gynecological or obstetric conditions that do not require intensive monitoring or specialized care. In this scenario, the most suitable patient for transfer to the Women's Health Center would be the 26-year-old woman who had a bowel resection, as her condition aligns more closely with the services provided in that unit. The other options, including a male patient, a critically ill patient on a ventilator, and an elderly patient with Alzheimer's disease, would not be appropriate for transfer to a Women's Health Center due to the specialized care they require, which may not align with the unit's focus and staffing capabilities.
4. Who typically owns a patient's medical record?
- A. The patient
- B. The physician
- C. The Legal Counsel of the Office
- D. No one owns a medical record
Correct answer: B
Rationale: The correct answer is 'The physician.' Physicians typically own their patients' medical records as they are the ones responsible for creating, updating, and maintaining these records. However, it is essential to note that patients have the legal right to access and obtain copies of their medical records. Choice A ('The patient') is incorrect as patients do not own their medical records, but they do have rights regarding access to them. Choice C ('The Legal Counsel of the Office') is incorrect as legal counsel typically do not own or have ownership rights over medical records. Choice D ('No one owns a medical record') is incorrect as medical records are owned by healthcare providers who create and maintain them, such as physicians.
5. 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.
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