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. Which of the following may be a cultural barrier that impacts a healthcare provider's ability to provide care or education to the client?
- A. A healthcare provider offers educational materials to a client that are written at an 8th-grade reading level
- B. A Vietnamese woman wants to use steaming in addition to her prescription antibiotics
- C. A healthcare provider uses pantomime to explain a procedure to a deaf client
- D. A Native American client requests a healing ritual before considering surgery
Correct answer: C
Rationale: Cultural barriers can impede communication, hindering a healthcare provider's ability to provide education or instructions about a client's care. In the context of cultural sensitivity, using pantomime to explain a procedure to a deaf client can be ineffective and inappropriate. This approach implies a lack of recognition of the importance of proper communication methods, such as sign language interpreters, which are crucial for effective communication with individuals who are deaf. Miscommunication is likely to occur if the client does not understand the gestures and actions of the healthcare provider. This scenario highlights the significance of understanding and respecting different cultural practices and communication needs to deliver optimal care and education. Choice A is incorrect because offering educational materials at an appropriate reading level demonstrates consideration for the client's literacy level, which can enhance understanding and compliance with medical instructions. Choice B is incorrect as incorporating a client's cultural practices, such as steaming, alongside prescribed treatments can be a part of culturally competent care. Choice D is incorrect as respecting a client's request for a healing ritual aligns with providing patient-centered care that acknowledges and integrates cultural beliefs and preferences.
3. A systemic sign of infection is ______________.
- A. swelling
- B. redness
- C. heat
- D. a lack of appetite
Correct answer: D
Rationale: The correct answer is 'a lack of appetite.' When a person experiences a systemic infection, they may exhibit signs that affect the entire body. A lack of appetite is a common systemic sign of infection, along with other symptoms like rapid pulse, fever, and an elevated white blood cell count. Swelling, redness, and heat are more indicative of localized inflammation or infection, rather than systemic involvement.
4. How do technological advances relate to HIPAA?
- A. Technology can expose us to HIPAA violations.
- B. Computers facilitate information sharing.
- C. Computer screens should be visible only to authorized personnel.
- D. Technology enhances HIPAA confidentiality.
Correct answer: A
Rationale: Technology can expose us to HIPAA violations. For instance, leaving a computer screen unattended and visible to unauthorized individuals can result in breaches of patient confidentiality, leading to HIPAA violations. While computers can indeed aid in sharing information, this is not directly related to HIPAA compliance. Ensuring that computer screens are only visible to authorized personnel is a good practice, but it does not address the broader risks and challenges posed by technological advancements in maintaining HIPAA compliance. Therefore, the correct answer is that technology can expose us to HIPAA violations.
5. A client is having blood tests and has an elevated lymphocyte level. Based on knowledge of cellular components, what does the nurse know about these cells?
- A. Contain histamine and provide protection during allergic reactions
- B. Are involved in phagocytosis
- C. Provide protection and immunity against foreign substances
- D. Carry hemoglobin and oxygen to body tissues
Correct answer: C
Rationale: Lymphocytes are a type of white blood cells that play a crucial role in supporting the body's immune system. They are responsible for producing substances that protect the body against infections and foreign substances that could potentially harm the client. Lymphocytes consist of two main types: T cells, which are produced in the thymus, and B cells, which are produced in the lymphatic tissue. Choice A is incorrect because histamine is mainly associated with basophils and mast cells, not lymphocytes. Choice B is incorrect as phagocytosis is a function of other white blood cells such as neutrophils and macrophages. Choice D is also incorrect as carrying hemoglobin and oxygen is a function of red blood cells, not lymphocytes.
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