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. 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.
3. While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?
- A. They are able to make simple associations of ideas
- B. They are able to think logically in organizing facts
- C. Interpretation of events originates from their own perspective
- D. Conclusions are based on previous experiences
Correct answer: B
Rationale: At the age of 10, children are in the concrete operations stage according to Piaget. They are capable of mature thought when allowed to manipulate and organize objects. This means they can think logically, organize facts, and understand cause-and-effect relationships. Choices A, C, and D are incorrect. While simple associations of ideas may occur, the key cognitive ability at this stage is the capacity for logical thought and organization of information. Interpretation of events from their own perspective is more characteristic of younger children, and conclusions based on previous experiences are more aligned with older children or adults.
4. Which of the following statements best describes substance P?
- A. Substance P decreases a client's sensitivity to pain
- B. Substance P levels are drawn before administration of narcotic analgesics
- C. Substance P is found in the brain and is responsible for pain control and management of depression
- D. Substance P is found in the dorsal horn of the spinal column
Correct answer: D
Rationale: Substance P is a neurotransmitter found in the brain and the dorsal horn of the spinal column, not just in the brain. It is associated with pain transmission and modulation. Substance P is known to cause inflammation, edema, and pain. While it plays a role in pain perception, it does not decrease a client's sensitivity to pain (Choice A), nor are its levels typically drawn before administering narcotic analgesics (Choice B). Although substance P is involved in pain control, it is not responsible for managing depression (Choice C). Therefore, the correct statement is that substance P is found in the dorsal horn of the spinal column.
5. A client is being instructed on how to use crutches. Which of the following information should be included in the teaching?
- A. Place the majority of body weight on the axilla.
- B. Dry crutch tips with a paper towel if they become wet.
- C. Use the crutches for support to lift both feet simultaneously when ascending stairs.
- D. Both B and C.
Correct answer: B
Rationale: When instructing a client on how to use crutches for ambulation, it is important to emphasize keeping the crutch tips dry to prevent slipping while bearing weight on them. Moisture on the crutch tips can lead to accidents. Therefore, the correct answer is to dry the crutch tips with a paper towel if they become wet. Choice A, placing the majority of body weight on the axilla, is incorrect as the weight should be borne through the hands, not the axilla, to avoid nerve damage. Choice C, using the crutches to lift both feet simultaneously when ascending stairs, is incorrect as the client should ascend stairs by placing weight on the unaffected leg first, followed by the crutches and then the affected leg. This method provides stability and safety during stair climbing.
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