NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. In the term 'Hemoglobin,' the suffix '-globin' means:
- A. Protein
- B. Iron
- C. Metal
- D. Blood
Correct answer: A
Rationale: The suffix '-globin' in the term 'Hemoglobin' specifically refers to a protein. Hemoglobin is a protein found in red blood cells that carries oxygen. Choice B, 'Iron,' is incorrect as iron is a mineral component of hemoglobin but not the meaning of the suffix. Choice C, 'Metal,' is too broad and not specific to the meaning of the suffix in this context. Choice D, 'Blood,' is incorrect as it refers to the overall term 'Hemoglobin' rather than the specific meaning of the suffix '-globin.' Therefore, the correct answer is A: 'Protein.'
2. A patient has a goal of eating at least 50% of each meal. The patient refuses to eat, so a nurse force-feeds the patient in order for them to reach their goal of eating at least 50% of the meal. The nurse has committed __________ against this patient.
- A. assault
- B. battery
- C. physical neglect
- D. emotional neglect
Correct answer: B
Rationale: The correct answer is 'battery.' Battery occurs when there is unwanted physical contact or force applied to a person without their consent. In this scenario, force-feeding the patient against their will constitutes battery as the nurse is physically interfering with the patient's body without permission. Assault involves the threat of physical harm, which is not present in the situation described. Physical neglect refers to the failure to provide basic care needs, which is not the case here. Emotional neglect involves the failure to address emotional needs, which is also not applicable in this context.
3. While caring for Mr. Charles Y., you see a notation on the nursing care plan that states, 'remind the patient to use the incentive spirometer tid.' This patient will be reminded at which of the following times?
- A. 10:00 AM
- B. 10 am and 2 pm
- C. 10 am, 2 pm, and 6 pm
- D. 10 am, 2 pm, 6 pm, and 10 pm
Correct answer: C
Rationale: The abbreviation 'tid' stands for 'ter in die,' which means three times a day. In this case, the patient should be reminded to use the incentive spirometer at 10 am, 2 pm, and 6 pm. Option A, '10 am,' is too infrequent for tid dosing. Option B, '10 am and 2 pm,' is missing the third reminder at 6 pm. Option D, '10 am, 2 pm, 6 pm, and 10 pm,' includes an additional time that is not part of the standard tid dosing schedule.
4. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?
- A. 240 cc
- B. 120 cc
- C. 8 cc
- D. 0 cc because Italian ice is not a fluid
Correct answer: A
Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.
5. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?
- A. The client's IV is infiltrated
- B. The client is experiencing phlebitis from the last drug administered
- C. The client has a blood clot developing in the distal arteries of the wrist
- D. The client's pain is associated with myocardial ischemia and he is having a heart attack
Correct answer: A
Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.
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