NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. A woman has died as a result of a motor vehicle accident. She is listed as an organ donor, and her family is considering whether to comply with her wishes. Which of the following is true?
- A. The woman would have had to list herself as an organ donor and notify her family before her death that she has considered donating her organs.
- B. The Uniform Anatomical Gift Act requires the physician caring for the patient to inform the family who receives the donor organs.
- C. Physicians can choose to go against the deceased's wishes if the family decides that organ donation is not an acceptable choice.
- D. Physicians have the legal responsibility to inform patients of the risks involved in donating organs.
Correct answer: D
Rationale: In cases where a deceased person is listed as an organ donor, the family may have the final say on whether to proceed with organ donation, even if the individual had expressed their wish to donate. Physicians may prioritize the emotional well-being of the family over the wishes of the deceased, especially if organ donation could cause additional distress or trauma to the grieving family members. Therefore, it is possible for physicians to respect the family's decision not to proceed with organ donation, even if the deceased had previously expressed the desire to donate. This decision-making process underscores the importance of considering and respecting the perspectives and emotions of both the deceased individual and their surviving family members in organ donation scenarios.
2. Which of the following white blood cells is the smallest and can be involved in humoral immunity?
- A. Lymphocyte
- B. Monocyte
- C. Basophil
- D. Erythrocyte
Correct answer: A
Rationale: The correct answer is 'Lymphocyte.' Lymphocytes are the smallest type of white blood cells and play a crucial role in humoral immunity by producing antibodies. Monocytes are actually the largest white blood cells and are involved in phagocytosis rather than humoral immunity. Basophils are a type of granulocyte involved in allergic reactions, and erythrocytes are red blood cells responsible for oxygen transport, not part of the immune system.
3. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, "My blood pressure is usually much lower."? The nurse should tell the client to:
- A. Go get a blood pressure check within the next 15 minutes
- B. Check blood pressure again in two (2) months
- C. See the healthcare provider immediately
- D. Visit the healthcare provider within one (1) week for a BP check
Correct answer: A
Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke. Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (Choice B) or a week (Choice D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (Choice C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.
4. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?
- A. "I want to protect my child from any falls."?
- B. "I will set limits on exploring the house."?
- C. "I understand the need to use those new skills."?
- D. "I intend to keep control over our child."?
Correct answer: C
Rationale: The correct answer is: "I understand the need to use those new skills."? This response indicates that the mother recognizes the importance of allowing the toddler to practice and develop new skills, supporting autonomy and exploration. Setting limits, protecting from falls, and intending to keep control go against the toddler's developmental needs. Toddlers at this stage require opportunities to explore, practice new skills, and gain independence to foster healthy development.
5. A nurse is using active listening as a form of therapeutic communication when:
- A. She uses humor to put the client at ease in a situation
- B. She restates what the client said in slightly different words
- C. She uses eye contact and maintains an open stance while the client is talking
- D. She provides personal information to show the client she can relate to him
Correct answer: C
Rationale: Active listening is a form of therapeutic communication that involves the nurse encouraging a client to express their thoughts and feelings. Maintaining eye contact and an open stance while the client is talking demonstrates active listening and shows the client that they are being heard and understood. Using humor (Choice A) may not always be appropriate or therapeutic in all situations. Restating what the client said (Choice B) is a technique known as paraphrasing and is also a form of active listening. Providing personal information (Choice D) can shift the focus from the client to the nurse, which is not the intention of active listening.
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