NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. When a nurse is asked by a physician to speak to a colleague about their unprofessional behavior in front of a client but chooses not to confront the colleague and avoids the physician the next day, what type of conflict resolution is the nurse exhibiting?
- A. Accommodation
- B. Competition
- C. Avoidance
- D. Negotiation
Correct answer: C
Rationale: The nurse is exhibiting the conflict resolution strategy of avoidance. Avoidance involves ignoring the problem in the hope that it will go away on its own. In this scenario, the nurse avoids confronting the colleague and stays away from the physician, which does not address the issue directly. While avoidance may provide time for others to gain insight into the situation, it typically does not lead to a resolution of the underlying problems. Accommodation (A) involves yielding to the wishes of others, competition (B) entails pursuing one's own concerns at the expense of others, and negotiation (D) involves seeking a mutually agreeable solution through communication and compromise, none of which are demonstrated by the nurse in this situation.
2. A nurse is caring for an 83-year-old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:
- A. Keep the client in an upright position at all times
- B. Auscultate lung sounds every shift and after feedings
- C. Maintain suction equipment at the client's bedside
- D. Instruct the client about how to perform swallowing exercises
Correct answer: A
Rationale: When caring for a client with swallowing difficulties, it is crucial to prevent aspiration of food into the lungs. Appropriate interventions include auscultating lung sounds every shift and after feedings to assess for any changes in breathing patterns, maintaining suction equipment at the client's bedside in case of difficulties, and providing instruction on swallowing exercises. Keeping the client in an upright position at all times is not necessary and may not always be feasible or comfortable for the client. This rigid requirement is not part of the standard care protocol for managing swallowing difficulties.
3. Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with:
- A. Auditory hallucinations
- B. Bizarre behaviors
- C. Ideas of reference
- D. Motivation for activities
Correct answer: D
Rationale: In clients with negative symptoms of schizophrenia, such as Jaime, a common problem is avolition, which is the lack of motivation for activities. These 'negative' symptoms are characterized by inexpressive faces, blank looks, monotone speech, few gestures, and a seeming lack of interest in the world. Patients may also experience an inability to feel pleasure or act spontaneously. It is crucial to differentiate between the lack of expression and lack of feeling, as well as between lack of will and lack of activity. Auditory hallucinations (choice A) are positive symptoms, not typically associated with negative symptoms of schizophrenia. Bizarre behaviors (choice B) are more aligned with positive symptoms like disorganized behavior. Ideas of reference (choice C) involve incorrectly interpreting casual incidents and external events as having direct reference to oneself, which is not directly related to motivation for activities seen in negative symptoms.
4. You are turning your patient in bed and notice that a confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for due to all three of these factors: confusion, lethargy, and items in the bed?
- A. Falls
- B. Skin breakdown
- C. Apnea
- D. Lack of mobility
Correct answer: B
Rationale: This patient is at great risk for skin breakdown due to the presence of three specific risk factors: confusion, lethargy, and items in the bed. While confusion puts the patient at risk for falls, confusion and lethargy together may lead to a lack of mobility. However, skin breakdown is the primary concern in this scenario as it is associated with all three risk factors - confusion, lethargy, and the presence of items in the bed. Therefore, the correct answer is 'Skin breakdown'.
5. A nurse is providing dismissal instructions for a child who was admitted for rotavirus. Which of the following statements by the parent indicates the need for further teaching?
- A. I'll start giving him his antibiotics as soon as we get home.
- B. I will call the physician if he becomes dizzy or overly fussy.
- C. He will need to wash his hands a lot to keep this from spreading.
- D. I'll watch to see when he stops having diarrhea stools.
Correct answer: A
Rationale: The correct answer is 'I'll start giving him his antibiotics as soon as we get home.' Rotavirus is a viral illness, and antibiotics are ineffective for its treatment. The parent's statement indicates a need for further teaching as antibiotics are not appropriate for treating rotavirus. Option B is correct as it demonstrates the parent's understanding of when to contact the physician for concerning symptoms. Option C is a correct statement regarding infection control practices. Option D is also correct as monitoring diarrhea stools is essential to track recovery from rotavirus.
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