NCLEX-RN
NCLEX RN Exam Prep
1. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?
- A. Assist the client in using the bathroom one hour after going to bed
- B. Give the client a massage before bedtime
- C. Tuck bed sheets and blankets tightly around the client once settled in bed
- D. Give the client a pair of socks to wear if their feet become cold
Correct answer: D
Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.
2. The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?
- A. Belief in and worship of God or gods
- B. Being closely tied to one's ethnic background
- C. Attendance at a specific church or place of worship
- D. A connection with something larger than oneself and belief in transcendence
Correct answer: D
Rationale: Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Choice A, 'Belief in and worship of God or gods,' and choice C, 'Attendance at a specific church or place of worship,' are more aligned with religious practices. Choice B, 'Being closely tied to one's ethnic background,' is not a defining aspect of spirituality or religion as it pertains more to cultural identity rather than spiritual beliefs.
3. The nurse is unable to palpate the right radial pulse on a patient. What would the nurse do next?
- A. Auscultate over the area with a fetoscope.
- B. Use a goniometer to measure the pulsations.
- C. Use a Doppler device to check for pulsations over the area.
- D. Check for the presence of pulsations with a stethoscope.
Correct answer: C
Rationale: When a nurse is unable to palpate a radial pulse, the next step is to use a Doppler device to check for pulsations over the area. Doppler devices are specifically designed to augment pulse or blood pressure measurements. Auscultating with a fetoscope is used to listen to fetal heart tones and is not relevant in this scenario. Goniometers are used to measure joint range of motion and are not used to assess pulses. Stethoscopes are primarily used to auscultate breath, bowel, and heart sounds, not to check for pulsations in peripheral pulses. Therefore, the correct course of action when unable to palpate a pulse is to utilize a Doppler device to assess for pulsations in the radial pulse area.
4. To which of the following do the CDC Standard precautions recommendations apply?
- A. Patients with diagnosed infections only
- B. Blood or body fluids with visible blood only
- C. All body fluids including sweat
- D. All patients receiving care in hospitals
Correct answer: D
Rationale: The correct answer is 'All patients receiving care in hospitals.' Standard precautions apply to all patients in healthcare settings, regardless of their infection status. These recommendations include all body fluids except sweat, non-intact skin, and mucous membranes. Choice A is incorrect as standard precautions are not limited to patients with diagnosed infections. Choice B is incorrect as standard precautions extend beyond blood or body fluids with visible blood. Choice C is incorrect as sweat is an exception to the body fluids covered under standard precautions.
5. A 60-year-old patient has been treated for pneumonia for the past 6 weeks. The patient is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. Which is an appropriate rationale for this patient's weight loss?
- A. Chronic diseases such as hypertension do not usually cause weight loss.
- B. Weight loss is more likely due to underlying medical conditions than unhealthy eating habits.
- C. Unexplained weight loss often accompanies short-term illnesses.
- D. Weight loss is not typically caused by mental health dysfunctions.
Correct answer: C
Rationale: Unexplained weight loss in a patient with pneumonia could indicate an underlying short-term illness or a chronic condition like endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Hypertension is not commonly associated with weight loss; it usually leads to weight gain due to fluid retention. Unhealthy eating habits are less likely to explain significant unexplained weight loss over a short period. Mental health dysfunctions can affect appetite but are not typically primary causes of significant unexplained weight loss.
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