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. You are taking care of a patient who has active TB. The patient has been put on airborne precautions and is in a special room. You must wear a HEPA mask when you enter the room. Now, the patient has to leave the room and go to the radiology department. How can you transport this patient to the radiology department without spreading TB throughout the hospital?
- A. Have everyone along the route to the radiology department wear a HEPA mask.
- B. Have patients along the route to the radiology department wear a HEPA mask.
- C. Have staff along the route to the radiology department wear a HEPA mask.
- D. Place a HEPA mask on the patient.
Correct answer: D
Rationale: To prevent the spread of TB throughout the hospital, it is essential to place a HEPA mask on the patient before transporting them to the radiology department. Expecting everyone along the route to wear a HEPA mask is not practical due to the high cost and the need for special fittings. Having patients or staff wear HEPA masks along the route is also not feasible and may not effectively contain the spread of TB.
4. When would chest thrusts be performed in an emergency situation?
- A. When performing CPR to initiate cardiovascular circulation.
- B. When assessing responsiveness of an unconscious patient.
- C. When assisting a pregnant woman who is choking.
- D. None of the above examples indicate the need for chest thrusts.
Correct answer: C
Rationale: In the scenario of an emergency where a pregnant woman is choking, chest thrusts are performed to clear the airway obstruction. This technique is used instead of abdominal thrusts to avoid potential harm to the fetus. While chest thrusts are not as effective as abdominal thrusts in clearing obstructions, they are the preferred method in this specific situation. Choices A and B are incorrect as chest thrusts are not typically performed during CPR to initiate cardiovascular circulation or when assessing responsiveness of an unconscious patient. Choice D is incorrect as chest thrusts are indeed warranted when assisting a pregnant woman who is choking.
5. A patient with Parkinson's disease is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care?
- A. Anorexia
- B. Aspiration
- C. Self-care deficit
- D. Inadequate intake
Correct answer: B
Rationale: When a person experiences dysphagia (difficulty swallowing), the greatest concern is aspiration. Aspiration occurs when food or fluids enter the trachea and lungs instead of going down the esophagus. This can lead to serious complications such as choking, airway obstruction, and aspiration pneumonia. Anorexia (Choice A) refers to a loss of appetite, which is not the primary concern with dysphagia. Self-care deficit (Choice C) and inadequate intake (Choice D) are important considerations but do not have as direct an impact on the immediate safety and health risks associated with aspiration in dysphagia.
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