NCLEX-RN
NCLEX RN Exam Review Answers
1. 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.
2. A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?
- A. Family history of heart disease
- B. Overweight
- C. Smoking
- D. Age
Correct answer: A
Rationale: A family history of heart disease is an inherited risk factor for developing atherosclerosis. This factor is not modifiable through lifestyle changes. Studies have shown that having a first-degree relative with heart disease significantly increases the individual's risk of developing atherosclerosis. Overweight, smoking, and age are not hereditary risk factors for atherosclerosis. Overweight and smoking are lifestyle-related risk factors, while age is a non-modifiable risk factor that increases with time but is not directly inherited.
3. A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?
- A. Contact the state board of nursing licensure to report the offense
- B. Review the state scope of practice standards for nurses
- C. Ask another nurse to perform the task to learn the procedure
- D. Contact the house supervisor to make the decision on whether the nurse should perform the task
Correct answer: B
Rationale: When faced with a task that a nurse believes may be beyond their scope of practice, it is essential to refer to the state's specific scope of practice standards for nurses. This step is crucial as these standards can vary between states, providing clarity on what tasks are permissible. By reviewing these standards, the nurse can determine if the task falls within their scope of practice. Contacting the state board of nursing licensure to report the offense (Choice A) is premature and should only be considered if there is a serious violation after reviewing the scope of practice. Asking another nurse to perform the task (Choice C) does not address the issue of clarifying the scope of practice. Contacting the house supervisor (Choice D) may be necessary if the nurse cannot determine the appropriateness of the task based on the scope of practice standards.
4. Which of the following white blood cells is the smallest and can be involved in humoral immunity?
- A. Lymphocyte
- B. Monocyte
- C. Basophil
- D. Erythrocyte
Correct answer: A
Rationale: The correct answer is 'Lymphocyte.' Lymphocytes are the smallest type of white blood cells and play a crucial role in humoral immunity by producing antibodies. Monocytes are actually the largest white blood cells and are involved in phagocytosis rather than humoral immunity. Basophils are a type of granulocyte involved in allergic reactions, and erythrocytes are red blood cells responsible for oxygen transport, not part of the immune system.
5. A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?
- A. Delirium
- B. Muscle rigidity
- C. Hypotension
- D. Pinpoint rash
Correct answer: A
Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.
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