NCLEX-RN
NCLEX RN Exam Prep
1. A nursing care plan states, 'Assist the patient to the bedside commode PRN.' When will this patient get this assistance to the commode?
- A. Whenever needed
- B. At bedtime
- C. During the night
- D. During the day
Correct answer: A
Rationale: The correct answer is 'Whenever needed.' The abbreviation 'PRN' stands for 'pro re nata,' which translates to 'as needed' or 'whenever necessary.' This means that the patient will receive assistance to the commode whenever they require it, based on their individual needs and condition. Choices B, C, and D are incorrect because 'PRN' does not specify a specific time like bedtime, during the night, or during the day; instead, it indicates assistance based on the patient's needs.
2. What would be an appropriate evaluation statement for the nurse to write based on the client's ability to state only two signs of impaired circulation out of three as expected?
- A. Client understands the signs of impaired circulation
- B. Goal met: Client cited numbness and tingling as a sign of impaired circulation
- C. Goal not met: Client able to name only two signs of impaired circulation
- D. Goal not met: Client unable to describe signs of impaired circulation
Correct answer: C
Rationale: The appropriate evaluation statement for the nurse to write would be 'Goal not met: Client able to name only two signs of impaired circulation.' In this scenario, the client has only identified two out of the three signs of impaired circulation specified in the desired outcome. Therefore, the goal has not been fully achieved. It is essential in nursing practice to assess and document client progress accurately. While the client has shown some understanding by correctly identifying numbness and tingling as signs of impaired circulation, the inability to state the third sign indicates an incomplete achievement of the goal. This evaluation helps guide further interventions or educational strategies to help the client meet the desired outcome in the care plan.
3. When a patient is standing in anatomical position, where are their feet?
- A. Facing forward with the toes spread open
- B. Facing out to the sides to open the hips
- C. Side by side and facing forward; toes resting comfortably
- D. The feet are pointed inward.
Correct answer: B
Rationale: When a person is standing in anatomical position, their feet are side by side, and they are facing forward with the toes pointing out to the sides to open the hips. This position allows for proper alignment of the body for anatomical reference. Choice A is incorrect because the feet should not be spread open, but rather side by side. Choice C is incorrect as it does not mention the correct positioning of the feet. Choice D is incorrect as the feet should not be pointed inward, but rather facing out to the sides to open the hips.
4. Which of the following is an example of emotional abuse?
- A. A slap to the person's hand
- B. Threatening the person
- C. Ignoring and isolating a person
- D. Leaving a patient soiled for hours
Correct answer: C
Rationale: Emotional abuse involves behaviors that harm an individual's self-worth and emotional well-being. Threatening someone instills fear and causes psychological distress, making it a clear example of emotional abuse. Choices A, C, and D involve physical abuse, neglect, and neglect of care, respectively, rather than emotional abuse. A slap to the person's hand constitutes physical abuse, ignoring and isolating a person is neglectful behavior, and leaving a patient soiled for hours falls under neglect of care.
5. When preparing to perform a physical examination on an infant, what should the nurse do?
- A. Have the parent remove all clothing except the diaper.
- B. Instruct the parent not to feed the infant immediately before the examination.
- C. Allow the infant to suck on a pacifier during abdominal auscultation.
- D. Ensure the parent is present during the examination.
Correct answer: A
Rationale: For performing a physical examination on an infant, it is important to have the parent remove all clothing except the diaper to allow for a thorough examination while ensuring the infant remains comfortable. It is recommended not to feed the infant immediately before the examination but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. While a pacifier may be used during invasive assessments or if the infant is crying, it is not typically necessary during abdominal auscultation. Having the parent present during the examination is important for the infant's security and for the parent to understand the process; however, the clothing should still be removed except for the diaper to facilitate a comprehensive assessment.
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