NCLEX-RN
NCLEX RN Exam Prep
1. A patient has a goal of eating at least 50% of each meal. The patient refuses to eat, so a nurse force-feeds the patient in order for them to reach their goal of eating at least 50% of the meal. The nurse has committed __________ against this patient.
- A. assault
- B. battery
- C. physical neglect
- D. emotional neglect
Correct answer: B
Rationale: The correct answer is 'battery.' Battery occurs when there is unwanted physical contact or force applied to a person without their consent. In this scenario, force-feeding the patient against their will constitutes battery as the nurse is physically interfering with the patient's body without permission. Assault involves the threat of physical harm, which is not present in the situation described. Physical neglect refers to the failure to provide basic care needs, which is not the case here. Emotional neglect involves the failure to address emotional needs, which is also not applicable in this context.
2. Which bloodborne pathogen is the most virulent? (Choose the BEST answer.)
- A. HCV
- B. HPV
- C. HIV
- D. HBV
Correct answer: A
Rationale: The correct answer is HCV (Hepatitis C Virus). Hepatitis C is considered the most virulent bloodborne pathogen, being 100 times more virulent than Hepatitis B. HPV (Human Papillomavirus) is a sexually transmitted infection but is not a bloodborne pathogen. HIV (Human Immunodeficiency Virus) affects the immune system but is not as virulent as Hepatitis C in terms of bloodborne transmission. HBV (Hepatitis B Virus) is less virulent compared to HCV in the context of bloodborne transmission.
3. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?
- A. Avoid palpating reportedly “tender” areas as this may cause pain.
- B. Palpate tender areas quickly to minimize patient discomfort.
- C. Initiate the assessment with deep palpation while encouraging the patient to relax and take deep breaths.
- D. Begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch.
Correct answer: D
Rationale: The correct approach is to begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch. This allows the nurse to first assess surface features before proceeding to deeper palpation. Starting with light palpation also helps the patient become more comfortable with being touched, creating a smoother examination experience. Palpating tender areas quickly, as suggested in choice B, can increase patient discomfort. Deep palpation, as in choice C, is typically performed after light palpation to avoid discomfort and ensure proper assessment. Avoiding palpation of tender areas first, as in choice A, helps prevent causing unnecessary pain and should be done towards the end of the assessment.
4. Which of the following items of subjective client data would be documented in the medical record by the nurse?
- A. Client's face is pale
- B. Cervical lymph nodes are palpable
- C. Nursing assistant reports client refused lunch
- D. Client feels nauseated
Correct answer: D
Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.
5. Should standard precautions be used when providing post mortem care to a patient who has died from a massive heart attack and had no other diseases, illnesses, or infections?
- A. Yes, because the patient must be treated with respect
- B. Yes, you still must use standard precautions
- C. No, because the patient had no infections
- D. No, because this is not respectful
Correct answer: B
Rationale: Yes, you must still use standard precautions when providing post mortem care, regardless of the patient's medical history. Standard precautions are essential to prevent the transmission of potential infectious agents and protect both the healthcare provider and others from exposure. Even if the patient did not have known infections, it is crucial to maintain a safe environment and uphold professional standards of care. Choice A is incorrect as using standard precautions is primarily for infection control rather than solely for respect. Choices C and D are incorrect as the absence of infections or the notion of respect does not negate the need for standard precautions in post mortem care.
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