NCLEX-RN
NCLEX RN Exam Review Answers
1. A patient scheduled for cataract surgery asks the nurse why they developed cataracts and how to prevent it in the future. What is the nurse's best response?
- A. Age is the biggest factor contributing to cataracts.
- B. Unprotected exposure to UV lights can cause cataracts.
- C. Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.
- D. Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions.
Correct answer: C
Rationale: The correct answer is C: 'Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.' This response is the best choice as it covers the most common contributing factors for cataracts and includes preventable risk factors. Choice A is incorrect because while age is a significant factor in cataract development, it is not the only one. Choice B is incorrect as UV light exposure is a risk factor for cataracts but not the most comprehensive response. Choice D is incorrect as there are preventive measures individuals can take to reduce their risk of developing cataracts, such as protecting their eyes from UV light and managing other risk factors.
2. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is
- A. maintaining normal respiratory function.
- B. expressing satisfaction with pain control.
- C. developing no ongoing pancreatic disease.
- D. having adequate fluid and electrolyte balance.
Correct answer: A
Rationale: In acute severe pancreatitis, there is a risk of respiratory failure as a complication, making the maintenance of normal respiratory function the priority outcome. This patient may develop respiratory issues due to the inflammatory process affecting the diaphragm. While pain control, absence of ongoing pancreatic disease, and fluid/electrolyte balance are crucial, they are secondary to ensuring adequate oxygenation and ventilation to prevent respiratory compromise.
3. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?
- A. Rice
- B. Oatmeal
- C. Rye toast
- D. White bread
Correct answer: A
Rationale: In celiac disease, individuals are intolerant to gluten found in wheat, barley, rye, and oats. Therefore, it is crucial to eliminate these grains from the diet. Rice, corn, or millet are safe alternatives for individuals with celiac disease. Oatmeal is generally avoided unless specifically labeled as gluten-free due to possible cross-contamination. Rye toast and white bread contain gluten and should be avoided in celiac disease. Vitamin supplements may also be necessary to address deficiencies caused by dietary restrictions.
4. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening.
- B. Perform tests for sexually transmitted diseases.
- C. Discuss her high risk for cervical cancer.
- D. Refer the client to a family planning clinic.
Correct answer: A
Rationale: In this scenario, the client's disclosure of having multiple sex partners and uncertainty about the baby's father indicates a potential high risk for HIV. Therefore, the priority nursing intervention is to counsel the woman to consent to HIV screening. Early detection of HIV is crucial for initiating timely treatment and improving outcomes. Choices B, C, and D are not the priority in this situation as HIV screening takes precedence over testing for other sexually transmitted diseases, discussing cervical cancer risk, or referring to a family planning clinic.
5. You have accompanied the physician into the family waiting room to tell a young husband that his wife has not survived the car accident she was in. The husband is crying and distraught. What is the most appropriate approach to supporting this family member?
- A. Ask if he would like to donate his wife's organs
- B. Sit quietly with him
- C. Ask about funeral arrangements
- D. Consult social services
Correct answer: B
Rationale: The most caring and supportive approach in a time of extreme distress is usually to sit quietly with the distressed individual until they have had the opportunity to absorb the news and gather themselves. Providing a supportive presence is often the most valuable tool a caregiver can use when circumstances bring overwhelming emotional pain to those they are caring for. Asking about organ donation at this moment may come off as insensitive and should not be a priority. Inquiring about funeral arrangements and consulting social services can be addressed later, once the husband has had time to process the initial shock and emotions.
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