NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. When is a physician likely to assess turgor?
- A. When iron deficiency is suspected.
- B. When heart and lung issues are suspected.
- C. When dehydration is suspected.
- D. None of the above.
Correct answer: C
Rationale: Skin turgor is assessed when dehydration is suspected. To evaluate skin turgor, a physician pinches the skin and observes how quickly it returns to its normal position. If the skin stays folded for an extended period, it indicates dehydration. Assessing turgor helps determine a patient's hydration status. Choice A is incorrect because skin turgor is not used to assess iron deficiency. Choice B is incorrect as turgor is not related to heart and lung issues, but rather hydration status. Choice D is incorrect as turgor assessment is relevant when dehydration is suspected.
2. Which term best describes changes such as retirement, grandparenting, and increased dependence on others?
- A. Moral
- B. Psychosocial
- C. Self-esteem
- D. Psychomotor
Correct answer: B
Rationale: The correct answer is 'Psychosocial.' Retirement, grandparenting, and increased dependence on others are examples of psychosocial changes because they involve social interactions, relationships, and psychological aspects. 'Moral' (Choice A) does not directly relate to the changes mentioned. 'Self-esteem' (Choice C) is more about self-perception and confidence, not the social changes mentioned. 'Psychomotor' (Choice D) refers to physical movements and skills, which are not the focus of the changes described in the question.
3. Which gland of the endocrine system secretes a hormone that assists with the sleep/wake cycle?
- A. Pituitary
- B. Pineal
- C. Pancreas
- D. Hypothalamus
Correct answer: B
Rationale: The correct answer is the Pineal gland. The Pineal gland, located in the brain, secretes melatonin, which plays a crucial role in regulating the sleep/wake cycle in response to exposure to light. The Pituitary gland (Choice A) secretes various hormones but not specifically related to the sleep/wake cycle. The Pancreas (Choice C) secretes insulin and digestive enzymes, not hormones related to the sleep/wake cycle. The Hypothalamus (Choice D) is involved in regulating many bodily functions, including hormone secretion, but it does not directly secrete the hormone that regulates the sleep/wake cycle.
4. What is the purpose of MSDS sheets?
- A. Contain the ordering information for each piece of equipment in the office.
- B. Are required by OSHA to be accessible to all employees of the office.
- C. Can be used to treat patients who have been injured in equipment accidents.
- D. None of the above.
Correct answer: B
Rationale: MSDS sheets, also known as Materials Safety Data Sheets, are essential documents that provide detailed information about chemicals used in the workplace. They are required by OSHA to be easily accessible to all employees to ensure they have the necessary information to handle chemicals safely. MSDS sheets do not contain ordering information for equipment in the office (Choice A) or serve as a treatment guide for injured patients (Choice C). Therefore, the correct answer is that MSDS sheets are required by OSHA to be accessible to all employees of the office.
5. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?
- A. A person of small stature is at increased risk for injury from entrapment.
- B. A history of a previous fall from a bed with raised side rails is significant.
- C. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails.
- D. Creative use of alternative measures indicates respect for the patient's dignity.
Correct answer: A
Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.
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