NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. 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.
2. A nurse with five years of experience working in a hospital unit is promoted as a mentor and preceptor to a new nursing staff. This is an example of:
- A. Collegiality
- B. Competence
- C. Advocacy
- D. Integration
Correct answer: A
Rationale: Collegiality is the action of forming relationships and supporting others through work experiences. In this scenario, the nurse being promoted as a mentor and preceptor exemplifies collegiality by fostering an encouraging educational relationship with the new nursing staff. The nurse demonstrates appropriate nursing care, teaches skills, and supports the professional growth of others. Choice B, 'Competence,' refers to having the necessary skills and knowledge, but in this context, the focus is on the supportive and educational role of the nurse. Choice C, 'Advocacy,' involves speaking up for patients' rights and needs, which is not directly demonstrated in the scenario. Choice D, 'Integration,' does not directly relate to the situation described, where the emphasis is on mentoring and guiding new staff.
3. How do technological advances relate to HIPAA?
- A. Technology can expose us to HIPAA violations.
- B. Computers facilitate information sharing.
- C. Computer screens should be visible only to authorized personnel.
- D. Technology enhances HIPAA confidentiality.
Correct answer: A
Rationale: Technology can expose us to HIPAA violations. For instance, leaving a computer screen unattended and visible to unauthorized individuals can result in breaches of patient confidentiality, leading to HIPAA violations. While computers can indeed aid in sharing information, this is not directly related to HIPAA compliance. Ensuring that computer screens are only visible to authorized personnel is a good practice, but it does not address the broader risks and challenges posed by technological advancements in maintaining HIPAA compliance. Therefore, the correct answer is that technology can expose us to HIPAA violations.
4. When a mother is inquiring about her child's ability to potty train, what is the most critical aspect of toilet training?
- A. The age of the child
- B. The child's ability to understand instructions
- C. The overall mental and physical abilities of the child
- D. Consistent attempts with positive reinforcement
Correct answer: C
Rationale: The most critical aspect of toilet training is the overall mental and physical abilities of the child. While age can play a role, it is not the sole determining factor. Understanding instructions is important but may not be the most critical aspect. Consistent attempts with positive reinforcement can be helpful, but without considering the child's abilities, it may not lead to successful potty training.
5. When a blood pressure cuff is too wide for a client's arm, what type of reading might this blood pressure cuff produce?
- A. A normal reading
- B. An abnormally low reading
- C. An abnormally high reading
- D. A fluctuating reading
Correct answer: B
Rationale: When a blood pressure cuff is too wide for a client's arm, it may produce an abnormally low blood pressure reading. This occurs because the oversized cuff can lead to an underestimation of blood pressure. It is essential to ensure that the cuff fits appropriately to obtain an accurate reading. An abnormally high reading (Choice C) is less likely with an oversized cuff, as it generally leads to lower readings. A normal reading (Choice A) is unlikely due to the inaccuracies caused by the oversized cuff. A fluctuating reading (Choice D) is not a typical result of using a cuff that is too wide; instead, it usually leads to consistently low readings.
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