NCLEX NCLEX-RN
NCLEX RN Exam Review Answers
1. A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?
- A. Heparin will dissolve clots that you have.
- B. Heparin will reduce the platelets that make your blood clot.
- C. Heparin will work better than warfarin.
- D. Heparin will prevent new clots from developing.
Correct answer: Heparin will prevent new clots from developing.
Rationale: The correct answer is D: 'Heparin will prevent new clots from developing.' Heparin is an anticoagulant medication that helps prevent the formation of new blood clots. It does not dissolve existing clots (choice A), reduce platelets (choice B), or necessarily work 'better' than warfarin (choice C) but rather functions differently. The primary action of heparin is to prevent the development of new clots, especially in conditions where clot formation is a concern.
2. A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
- A. Ask him to rate his pain on a scale of 1 to 10.
- B. Encourage him to wait until bedtime so the pill can help him sleep.
- C. Attend to the acutely ill client's needs first because this client is laughing.
- D. Instruct him in the use of deep breathing exercises for pain control.
Correct answer: Ask him to rate his pain on a scale of 1 to 10.
Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed to use it as a sleep medication, so encouraging him to wait until bedtime is incorrect. Option C is judgmental and inappropriate as all clients deserve prompt attention. Option D should be used as an adjunct to pain medication, not instead of medication, so instructing him in deep breathing exercises alone is not the priority in this situation.
3. Asepsis is defined as ________________.
- A. the absence of all microorganisms
- B. the absence of disease-causing germs
- C. a urinary infection
- D. a pathogenic infection
Correct answer: the absence of disease-causing germs
Rationale: Asepsis is defined as the absence of disease-causing germs. It is surgical asepsis that is defined as the absence of all microorganisms, including spores. A pathogenic infection is an invasion of the body by a pathogen, or disease-causing germ, and a urinary infection is only one type of infection.
4. 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: Only the healthcare proxy
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.
5. When a mother is inquiring about her child’s ability to potty train, what is the most critical aspect of toilet training?
- A. The age of the child
- B. The child’s ability to understand instructions
- C. The overall mental and physical abilities of the child
- D. Consistent attempts with positive reinforcement
Correct answer: The overall mental and physical abilities of the child
Rationale: The most critical aspect of toilet training is the overall mental and physical abilities of the child. While age can play a role, it is not the sole determining factor. Understanding instructions is important but may not be the most critical aspect. Consistent attempts with positive reinforcement can be helpful, but without considering the child's abilities, it may not lead to successful potty training.
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