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NCLEX RN Actual Exam Test Bank
1. During an assessment, a nurse asks a patient, “If you had fever and vomiting for 3 days, what would you do?” Which aspect of the mental status examination is the nurse assessing?
- A. Behavior
- B. Cognition
- C. Affect and mood
- D. Perceptual disturbances
Correct answer: B: Cognition
Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.
2. All of the following are essential components of supervision EXCEPT:
- A. All tasks to be delegated or supervised are within the nurse's scope of practice
- B. The necessary tasks require repeated assessments
- C. The nurse has adequate time to develop staff assignments
- D. Policies have been developed that govern nursing practice
Correct answer: The necessary tasks require repeated assessments
Rationale: Supervision in nursing requires key components to ensure effective management. Tasks to be delegated or supervised must align with the nurse's scope of practice to maintain safety and quality care. Adequate time for staff assignment development is essential for efficient workflow. Policies governing nursing practice provide a framework for safe and standardized care. However, the statement 'The necessary tasks require repeated assessments' is not an essential component of supervision. Tasks should be clear, achievable, and not necessitate repeated assessments, as this would impede delegation and efficient completion. Repeated assessments may indicate unclear task delegation or inadequate initial assessment, which should be avoided in effective supervision.
3. A client was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client?
- A. Whole grain cereal
- B. Eggs
- C. Cottage cheese
- D. Fish
Correct answer: Whole grain cereal
Rationale: Diverticulosis is a condition characterized by small protrusions in the intestinal tract. To manage diverticulosis, a high-fiber diet is recommended. Foods rich in fiber help prevent constipation and reduce the risk of inflammation in the intestines. Whole grain cereals are an excellent source of fiber and can aid in maintaining bowel regularity. Eggs, cottage cheese, and fish are not high-fiber foods and may not provide the necessary dietary support for a client with diverticulosis. While protein-rich foods like eggs and fish are beneficial for overall health, they are not the primary recommendation for managing diverticulosis.
4. Which of the following interventions should the nurse use when working with a Jackson-Pratt drain?
- A. Strip the tubing to remove clots by milking the tubing back toward the client
- B. Empty the drain when the amount of fluid reaches 25 cc
- C. Strip the tubing to remove clots by milking the tubing away from the client
- D. Maintain the level of the drain above the client's incision
Correct answer: Strip the tubing to remove clots by milking the tubing away from the client
Rationale: A Jackson-Pratt drain is a type of active wound drain that may be placed following a surgical procedure. This drain actively draws excess blood and fluid out of the wound. If clots develop within the tubing, the nurse should strip the tubing by milking it in a direction away from the client. This action helps to ensure the drain remains patent and effective. Option A is incorrect because the tubing should be milked away from the client, not towards. Option B is incorrect as the drain should be emptied based on the healthcare provider's orders, not at a fixed volume. Option D is incorrect because the level of the drain should be below the level of the incision to allow drainage by gravity.
5. A nursing unit is implementing a new electronic charting program for the nursing staff to use. Which of the following best describes a disadvantage of using electronic charting?
- A. The information is more likely to be lost or used inappropriately.
- B. Any provider in the unit can have access to the client's medical records.
- C. The system diminishes communication between nurses and providers.
- D. The program may be confusing and difficult to implement.
Correct answer: The program may be confusing and difficult to implement.
Rationale: A significant disadvantage of implementing a new electronic charting program is the potential for complexity and difficulty in implementation. Introducing a new system requires time and education for staff to adapt and use it appropriately. Users may experience confusion as they learn to navigate the new charting techniques, which can impact workflow efficiency and accuracy. Option A is incorrect because electronic charting systems are designed to enhance data security and integrity, reducing the risk of information being lost or misused. Option B is incorrect as access control mechanisms can restrict who can view specific patient records. Option C is incorrect as electronic charting systems often facilitate communication between healthcare providers by providing real-time access to patient information.
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