NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. A patient is having difficulty understanding how to properly run her glucose meter. Which of the following teaching methods would best help the patient understand how to use her instrument correctly?
- A. Give the patient an instruction booklet and encourage her to call the office if she has questions.
- B. Tell the patient to ask a healthcare provider to demonstrate how to use the instrument.
- C. Have the patient watch a video demonstrating the use of the instrument.
- D. Demonstrate the proper use of the instrument and then have the patient perform the process while still in the office.
Correct answer: D
Rationale: By using a demonstration and performance method of patient education, the patient is offered a chance to perform a task and have learning assessed while still in the office. This ensures that any questions that the patient has can be answered immediately, and any performance issues observed by the medical assistant can also be corrected promptly. Choice A is not as effective as providing a demonstration in person, as it may not address the patient's specific learning needs or allow for immediate feedback. Choice B suggests asking a healthcare provider to demonstrate, which is similar to the correct answer but may not always be readily available in the office. Choice C, watching a video, lacks the interactive component and immediate feedback that a live demonstration provides, making it less effective in this scenario.
2. The body system that functions to maintain fluid balance, support immunity, and contains the spleen is the:
- A. Lymphatic System
- B. Digestive System
- C. Urinary System
- D. Respiratory System
Correct answer: A
Rationale: The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.
3. Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.
- A. Client and Family
- B. Other nursing staff on the unit
- C. Security department
- D. Hospital administration
Correct answer: B
Rationale: Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.
4. You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to an LPN/LVN?
- A. Complete admission assessment.
- B. Set up oxygen and suction equipment.
- C. Place a padded tongue blade at the bedside.
- D. Pad the side rails before the patient arrives.
Correct answer: B
Rationale: The correct answer is to delegate the task of setting up oxygen and suction equipment to the LPN/LVN. This task falls within their scope of practice and can be safely performed by them. Completing the admission assessment (Choice A) typically requires a higher level of assessment and critical thinking, making it more appropriate for a registered nurse. Placing a padded tongue blade at the bedside (Choice C) involves potential airway management, which is a more complex task and should be done by a higher-level provider. Padding the side rails before the patient arrives (Choice D) is a task related to patient safety and should be done by the healthcare team as a whole, not solely delegated to an LPN/LVN.
5. Which of the following is the correct sequence for removing personal protective equipment?
- A. Remove gown, gloves, shoe covers, mask
- B. Remove mask, gloves, gown, shoe covers
- C. Remove gloves, gown, mask, shoe covers
- D. Remove shoe covers, mask, gloves, gown
Correct answer: C
Rationale: The correct sequence for removing personal protective equipment is crucial to prevent contamination. When exiting a surgical or aseptic situation, the proper sequence is to first remove gloves, followed by the gown, mask, and finally shoe covers. This order ensures that potentially contaminated items are removed first, minimizing the risk of exposure. Choice A, 'Remove gown, gloves, shoe covers, mask,' is incorrect as gloves should be removed before the gown. Choice B, 'Remove mask, gloves, gown, shoe covers,' is incorrect as gloves should be removed first. Choice D, 'Remove shoe covers, mask, gloves, gown,' is incorrect as gloves should be the first item removed to prevent contamination.
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