NCLEX-RN
NCLEX RN Exam Preview Answers
1. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?
- A. "Ethnicity is dynamic and ever-changing."?
- B. "Ethnicity is the belief in a higher power."?
- C. "Ethnicity pertains to a social group that may possess shared traits such as religion and language."?
- D. "Ethnicity is learned from birth through the processes of language acquisition and socialization."?
Correct answer: C
Rationale: Ethnicity pertains to a social group that may possess shared traits such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Culture is dynamic, ever-changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power. Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.
2. A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?
- A. Assist the client to lie in the semi-Fowler position
- B. Apply lubricating jelly to the tip of the catheter before insertion
- C. Instill a total of 30cc of fluid into the client's rectum
- D. Ask the client to hold the solution in for 30 seconds
Correct answer: B
Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.
3. When assisting a client with shampooing his hair while he is still in bed, a nurse raises the bed to approximately the level of her waist. What is the rationale for this action?
- A. To prevent shampoo from getting into the client's eyes
- B. To allow excess water to run off the edge of the bed
- C. To decrease strain on the nurse's back
- D. To prevent the client's hair from developing tangles
Correct answer: C
Rationale: Raising the bed to the level of the nurse's waist while assisting a client with shampooing in bed is done to reduce strain on the nurse's back. This adjustment ensures that the nurse can work comfortably without excessive bending or stooping, thus preventing back injuries. Choices A, B, and D are incorrect. While preventing shampoo from getting into the client's eyes, allowing excess water to run off the bed, and preventing hair tangles are important considerations, the primary rationale for raising the bed is to prioritize the nurse's ergonomic safety and prevent musculoskeletal strain.
4. The nurse is reviewing concepts related to one's heritage and beliefs. Which concept refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe?
- A. Culture
- B. Religion
- C. Ethnicity
- D. Spirituality
Correct answer: B
Rationale: Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services. Religion is a shared experience of spirituality or the values, beliefs, and practices into which people are either born or that they may adopt to meet their personal spiritual needs through communal actions, such as religious affiliation, attendance and participation in a religious institution, prayer, or meditation, and religious practices. Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It does not refer to a belief in a divine or superhuman power. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others. Spirituality is a broad term focused on a connection with something bigger than oneself and a belief in transcendence.
5. You are ready to wash your patient's face. You would start by washing what area of the face?
- A. The forehead
- B. The eyes
- C. The ears
- D. The cheeks
Correct answer: B
Rationale: When washing a patient's face, it is essential to start by cleaning the eyes. The eye area is considered the priority because moving from an area that can potentially be infected to areas of the face and body that are least able to become infected with a washcloth helps prevent the spread of germs. Washing the forehead, ears, or cheeks before the eyes may risk transferring bacteria to a more sensitive area like the eyes, which could lead to infections or other complications. Therefore, starting with the eyes ensures proper hygiene and reduces the risk of introducing harmful microorganisms to the patient's face.
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