NCLEX-RN
NCLEX RN Exam Review Answers
1. A client needs to give informed consent for electroconvulsive therapy treatments. Which of the following actions should the nurse take?
- A. Explain the adverse effects the client might experience from the treatment
- B. Verify the client gave consent voluntarily for the treatment
- C. Describe the benefits of the treatment to the client
- D. Outline possible alternatives to the treatment for the client
Correct answer: B
Rationale: When obtaining informed consent for a procedure like electroconvulsive therapy, the nurse's primary responsibility is to ensure that the client has given consent voluntarily and is capable of making such a decision. While it is essential to provide information on the treatment's benefits, risks, and alternatives, the priority is to verify the client's voluntary consent. Explaining the adverse effects and describing the benefits are important steps in the informed consent process, but the critical step is to confirm the client's voluntary agreement. Outlining possible alternatives to the treatment is also important but comes after ensuring the client's voluntary consent.
2. The BRAT diet is often prescribed for patients with gastroenteritis. This acronym stands for:
- A. Bananas, Rice, Applesauce, and Toast
- B. Bread, Rice, Apricots, and Tapioca
- C. Bananas, Rolls, Apricots, and Toast
- D. Bananas, Rolls, Applesauce, and Tapioca
Correct answer: A
Rationale: The BRAT diet, which stands for Bananas, Rice, Applesauce, and Toast, is commonly recommended for patients with gastroenteritis. These easily digestible foods help firm up stools due to their low fiber content and provide essential nutrients lost during vomiting and diarrhea. Choice B is incorrect because it includes apricots, which are not part of the traditional BRAT diet. Choice C is incorrect as it includes rolls, which are not typically included in the BRAT diet. Choice D is incorrect as it includes tapioca, which is not part of the traditional BRAT diet. Therefore, the correct answer is Bananas, Rice, Applesauce, and Toast.
3. At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?
- A. A diabetic client with a blood glucose level of 195 mg/dL
- B. A family member of an elderly client who has questions
- C. A client with COPD with an oxygen saturation of 84%
- D. A client who requires assistance to use the bathroom
Correct answer: C
Rationale: When prioritizing the needs of clients, the nurse must begin with the unstable client or manage conditions that affect airway, breathing, or circulation first. The client with COPD has a condition that affects breathing and is exhibiting decreased oxygen saturation levels; therefore, this client should be the first priority. Option A, the diabetic client with a blood glucose level of 195 mg/dL, does not present an immediate threat to airway, breathing, or circulation. Option B, addressing questions from a family member, is important but can be addressed after addressing critical patient needs. Option D, assisting a client to use the bathroom, is a routine task that can be prioritized after addressing urgent medical needs.
4. 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.
5. Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?
- A. A 65-year old male with urine output of 60cc in the past four hours
- B. A 2-month old female with a temperature of 100.6 rectally
- C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
- D. A 4-year old male with an oxygen saturation of 96% on room air
Correct answer: D
Rationale: Clients must meet a certain amount of set criteria before they will be discharged from a healthcare facility. Although guidelines may vary between locations, most healthcare facilities expect clients to have adequate oxygenation, nutrition, and elimination; and be free from fever, vomiting, and significant pain
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