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. When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?
- A. When the infant is sleeping
- B. At the end of the examination
- C. Before auscultation of the thorax
- D. At about the middle of the examination
Correct answer: B
Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.
3. A healthcare professional is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?
- A. Patient who is receiving chemotherapy for liver cancer
- B. Patient who is receiving chemotherapy for lung cancer
- C. Patient who has a wound infection after cholecystectomy
- D. Patient who requires pain management for chronic pancreatitis
Correct answer: D
Rationale: The patient with chronic pancreatitis is the best choice to admit to the same room as a patient who had a liver transplant and is experiencing acute rejection. This is because the patient with chronic pancreatitis does not pose an infection risk to the immunosuppressed patient who had a liver transplant. On the other hand, patients receiving chemotherapy for cancer or those with wound infections are at risk for infections, which could endanger the immunosuppressed patient with acute rejection.
4. What is the most effective step in hand washing?
- A. Using friction to remove potential pathogens.
- B. Using hospital-grade soap.
- C. Moisturizing the hands after washing to prevent cracking.
- D. Washing hands with soap for at least 15 seconds.
Correct answer: A
Rationale: The most effective step in hand washing is using friction to remove potential pathogens. While using soap, moisturizing hands, and washing for a sufficient duration are important aspects of hand hygiene, the mechanical action of rubbing hands together with friction is crucial in dislodging and removing dirt, debris, and potential pathogens. Hospital-grade soap may be beneficial, but the physical act of friction is key to effective hand washing. Moisturizing after washing is important for skin health but not the most effective step in the hand washing process. Simply washing hands for a specific duration, such as 15 seconds, without proper friction may not effectively remove contaminants. Therefore, using friction for thorough cleaning is the most crucial step in hand washing.
5. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?
- A. Collaborating with the client to establish healthcare goals
- B. Reviewing the client's medical record history
- C. Explaining the purpose of administered medications to the client
- D. Rapidly resetting priorities for client care based on changes in the client's condition
Correct answer: D
Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.
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