NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. Because of budget cuts in the hospital, the nursing manager informs the staff that they must either rotate to other units more often or take their turns staying home from work. Which principle is this nurse manager demonstrating?
- A. Justice
- B. Paternalism
- C. Veracity
- D. Fraternity
Correct answer: D
Rationale: Veracity involves truth-telling, even in challenging situations. In this scenario, the nurse manager is being transparent about the need for staff to rotate units or take turns staying home due to budget cuts. This allows the staff to make informed decisions about their work schedules and potential impact on their pay and work areas. Option A, Justice, does not apply as the focus is on communication and transparency, not fairness. Option B, Paternalism, does not fit as it involves decisions made for others' well-being without their input, which is not the case here. Option D, Fraternity, pertains to unity among individuals, which is not the principle demonstrated by the nurse manager in this situation.
2. What question must the nurse ask when formulating a nursing diagnosis?
- A. What diagnosis did the physician make for this client?
- B. What is the issue that I can solve for this client?
- C. What physician orders will resolve this issue?
- D. What underlying disease does this client have?
Correct answer: B
Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.
3. A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?
- A. Contact the state board of nursing licensure to report the offense
- B. Review the state scope of practice standards for nurses
- C. Ask another nurse to perform the task to learn the procedure
- D. Contact the house supervisor to make the decision on whether the nurse should perform the task
Correct answer: B
Rationale: When faced with a task that a nurse believes may be beyond their scope of practice, it is essential to refer to the state's specific scope of practice standards for nurses. This step is crucial as these standards can vary between states, providing clarity on what tasks are permissible. By reviewing these standards, the nurse can determine if the task falls within their scope of practice. Contacting the state board of nursing licensure to report the offense (Choice A) is premature and should only be considered if there is a serious violation after reviewing the scope of practice. Asking another nurse to perform the task (Choice C) does not address the issue of clarifying the scope of practice. Contacting the house supervisor (Choice D) may be necessary if the nurse cannot determine the appropriateness of the task based on the scope of practice standards.
4. When escorting a patient to the operating room on a stretcher, what should you do to prevent the patient from falling?
- A. Ensure the safety belt or strap is secured on the patient while escorting them to the operating room
- B. Use a safety belt or strap on the patient throughout their escort to the operating room
- C. Lower the bed position when moving the patient from the bed to the stretcher
- D. All of the above options are correct
Correct answer: B
Rationale: When escorting a patient to the operating room on a stretcher, it is crucial to secure a safety belt or strap on the patient to prevent falls during the transfer. This safety measure is not considered a restraint but a necessary precaution. Lowering the bed position is not necessary; in fact, the bed should be in a high position to align with the stretcher. Locking the wheels of the stretcher is essential to prevent accidents during patient transfer. Therefore, the correct action to prevent falls while moving a patient to the operating room is to use a safety belt or strap on the patient throughout the escort.
5. Which of the following situations might warrant a laboratory magnesium level?
- A. Hyperthyroidism
- B. Arthritis
- C. Ulcerative colitis
- D. Depression
Correct answer: C
Rationale: Ulcerative colitis can lead to symptoms such as abdominal pain, fever, diarrhea, and weight loss. This condition may impact the absorption of certain nutrients, including magnesium. Therefore, patients with chronic gastrointestinal conditions like ulcerative colitis should be screened for electrolyte imbalances related to impaired digestion. Hyperthyroidism, arthritis, and depression do not typically directly affect magnesium levels in the same way as gastrointestinal conditions like ulcerative colitis.
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