NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. Which of the following is one of the three smallest bones in the body?
- A. Vomer
- B. Distal phalanx of the small toe
- C. Stapes
- D. Coccyx
Correct answer: C
Rationale: The stapes, along with the malleus and incus, are the three smallest bones in the human body. These bones are located in the inner ear and play a crucial role in hearing. The vomer is a bone in the nasal cavity and is not one of the smallest bones. The distal phalanx of the small toe is relatively larger and not among the smallest bones. The coccyx, also known as the tailbone, is not one of the smallest bones in the body.
2. The body system that functions to maintain fluid balance, support immunity, and contains the spleen is the:
- A. Lymphatic System
- B. Digestive System
- C. Urinary System
- D. Respiratory System
Correct answer: A
Rationale: The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.
3. A nurse is caring for newborn infants in a nursery when a man enters the area to take his baby back to the room. The man does not have an identification bracelet, and the nurse does not recognize him. What is the next action of the nurse?
- A. Call security and ask them to escort the man out of the nursery
- B. Ask the man to wait and check the infant's chart
- C. Ask the man to return to his room and bring an identification band
- D. Allow the man to take the baby to his room
Correct answer: C
Rationale: The safety of infants in newborn nurseries is maintained by requiring parents to wear identification bracelets to identify themselves as the rightful parents. This practice minimizes the risk of mistakenly allowing an unauthorized individual to take a baby. In this scenario, since the nurse does not recognize the man and he lacks an identification bracelet, the appropriate action is to ask him to return to his room and bring the identification band. This step ensures the proper identity verification before allowing the man to take the baby. Calling security without first verifying the man's identity may escalate the situation unnecessarily. Checking the infant's chart alone does not confirm the man's identity. Allowing the man to take the baby without proper verification poses a safety risk to the infant.
4. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from?
- A. Cataracts
- B. Glaucoma
- C. Astigmatism
- D. Presbyopia
Correct answer: D
Rationale: Presbyopia is a condition that occurs when the lens of the eye loses accommodation and is unable to focus light on objects nearby. As a result, clients are unable to see or read items up close but may have success when holding the same item at arm's length. Many clients with presbyopia must wear bifocals, but long-distance vision remains unaffected. Cataracts involve clouding of the eye's lens, leading to blurry vision. Glaucoma is associated with increased intraocular pressure that damages the optic nerve, causing vision loss. Astigmatism is a refractive error where the cornea or lens has an irregular shape, leading to distorted or blurred vision.
5. Which of the following constitutes the five rights of medication administration?
- A. Right client, right nurse, right time, right dose, right route
- B. Right client, right time, right dose, right route, right order
- C. Right client, right drug, right dose, right time, right route
- D. Right physician, right nurse, right client, right drug, right dose
Correct answer: C
Rationale: The five rights of medication administration are essential to ensure safe and effective drug delivery to clients. The correct answer includes ensuring the right client receives the right drug at the right dose, via the right route, and at the right time. These elements are crucial to prevent medication errors and ensure optimal therapeutic outcomes. Choice A is incorrect as it includes 'right nurse' which is not part of the five rights of medication administration. Choice B is incorrect as it includes 'right order' which is not part of the five rights. Choice C is incorrect as it includes 'right drug' and 'right route', but it lacks 'right client' and 'right time'. Choice D is incorrect as it includes 'right physician' which is not part of the five rights.
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