NCLEX-RN
NCLEX RN Exam Prep
1. A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?
- A. Rigor mortis
- B. Postmortem decomposition
- C. Algor mortis
- D. Livor mortis
Correct answer: C
Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.
2. Who is legally able to make decisions for the patient or resident during a patient care conference when the patient is not mentally able to make decisions on their own?
- A. The patient or their healthcare proxy
- B. Only the patient
- C. Only the healthcare proxy
- D. The doctor
Correct answer: C
Rationale: When a patient is unable to make decisions due to mental incapacity, the healthcare proxy, designated by the patient in advance, has the legal authority to make decisions on the patient's behalf. In this situation, the patient lacks the capacity to make decisions independently. The healthcare proxy's role is to represent the patient's wishes and best interests. The doctor's role in a patient care conference is to provide medical expertise, offer recommendations, and assist in the decision-making process, but the final decision-making authority lies with the healthcare proxy, not the doctor.
3. A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: Less than body requirements
- B. Chronic low self-esteem
- C. Risk for suicide
- D. Hopelessness
Correct answer: B
Rationale: The priority nursing diagnosis in this scenario is 'Risk for suicide.' When a patient presents with major depression, significant weight loss, suicidal ideation, and lack of symptom improvement despite medication, the immediate concern is to address the risk of suicide. 'Risk for suicide' takes precedence as it involves a direct threat to the patient's life. 'Imbalanced nutrition: Less than body requirements' may be a concern but does not take priority over the risk of suicide. 'Chronic low self-esteem' and 'Hopelessness' are relevant issues in depression but are not as urgent as addressing the immediate risk of suicidal behavior.
4. The nurse is discussing the term subculture with a student nurse. Which statement by the nurse would best describe subculture?
- A. "Fitting as many people as possible into the majority culture."?
- B. "Identifying small groups of people who do not want to be identified with the larger culture."?
- C. "Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations."?
- D. "Recognizing groups of people within a culture with shared characteristics that are not common to all members of the culture."?
Correct answer: D
Rationale: A subculture refers to a group of people within a larger culture who share distinct beliefs, values, or attitudes that are not universal among all members of the larger culture. Subcultures can emerge based on factors such as ethnicity, religion, education, occupation, age, and gender. The correct answer describes the concept of a subculture accurately. Choices A, B, and C are incorrect because they do not capture the essence of a subculture. Fitting people into the majority culture, identifying small groups who distance themselves from the larger culture, or singling out individuals facing differential treatment do not define subculture. Subcultures represent specific groups with shared characteristics that differentiate them from the broader cultural norms.
5. How many cc are there in 25 ounces?
- A. 250
- B. 500
- C. 750
- D. 1000
Correct answer: C
Rationale: To convert ounces to cc, we know that there are 30 cc in 1 ounce. Therefore, to find out how many cc are in 25 ounces, we multiply 30 cc/ounce by 25 ounces which equals 750 cc. This makes choice C, 750, the correct answer. Choices A, B, and D are incorrect as they do not correctly convert ounces to cc.
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