NCLEX-RN
NCLEX RN Exam Prep
1. Nursing care plans are _______________?
- A. written by CNAs before they provide care
- B. guidelines of care that all nursing team members use
- C. used by nurses but not by nursing assistants
- D. used by nursing assistants but not by nurses
Correct answer: B
Rationale: Nursing care plans are comprehensive documents created by registered nurses to outline individualized care for patients. These plans serve as guidelines for all members of the nursing team, including nursing assistants, to ensure consistent and quality care. Choice A is incorrect as CNAs typically assist in implementing the care plan rather than creating it. Choice C is incorrect as nursing care plans are utilized by all members of the nursing team, not exclusive to only nurses. Choice D is incorrect as nursing assistants also utilize nursing care plans to provide patient care effectively.
2. A client is diagnosed with ariboflavinosis. Which of the following foods should the nurse serve this client?
- A. Citrus fruits
- B. Milk
- C. Fish
- D. Potatoes
Correct answer: B
Rationale: Ariboflavinosis is a vitamin B-2 deficiency. Symptoms may include cracks around the mouth, inflammation of the tongue, or light sensitivity. Foods rich in vitamin B-2, like milk, liver, green vegetables, or whole grains, are recommended. Citrus fruits (choice A) are good sources of vitamin C, not B-2. Fish (choice C) is a source of protein and omega-3 fatty acids but not a significant source of vitamin B-2. Potatoes (choice D) are a source of carbohydrates but do not provide high levels of vitamin B-2.
3. A healthcare professional is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?
- A. Patient who is receiving chemotherapy for liver cancer
- B. Patient who is receiving chemotherapy for lung cancer
- C. Patient who has a wound infection after cholecystectomy
- D. Patient who requires pain management for chronic pancreatitis
Correct answer: D
Rationale: The patient with chronic pancreatitis is the best choice to admit to the same room as a patient who had a liver transplant and is experiencing acute rejection. This is because the patient with chronic pancreatitis does not pose an infection risk to the immunosuppressed patient who had a liver transplant. On the other hand, patients receiving chemotherapy for cancer or those with wound infections are at risk for infections, which could endanger the immunosuppressed patient with acute rejection.
4. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?
- A. Respirations should be counted for 1 full minute.
- B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
- C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
- D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.
Correct answer: A
Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.
5. What does the medical term 'diaphoresis' mean?
- A. Profuse vomiting
- B. Profuse sweating
- C. Gasping for air
- D. None of the above
Correct answer: B
Rationale: The correct answer is B: Profuse sweating. Diaphoresis is a medical term that refers to excessive sweating. It is commonly seen in emergency situations such as heart attacks or diabetic episodes. Choice A, 'Profuse vomiting,' is incorrect as diaphoresis is not related to vomiting. Choice C, 'Gasping for air,' is also incorrect as it refers to difficulty breathing, not sweating. Choice D, 'None of the above,' is incorrect as diaphoresis specifically relates to sweating.
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