NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. What is the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance, as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well?"? The patient will:
- A. demonstrate improved social skills
- B. express a desire to interact with others
- C. become more independent in decision-making
- D. select and participate in one group activity per day
Correct answer: D
Rationale: The correct outcome for the patient with impaired social interaction related to sociocultural dissonance is to select and participate in one group activity per day. This outcome focuses on increasing social involvement, which aligns with addressing the nursing diagnosis. The patient has already expressed a desire to interact with others, so the goal is to facilitate actual participation in social activities. Becoming more independent in decision-making and demonstrating improved social skills are not directly related to the specific nursing diagnosis provided. Additionally, the outcomes must be measurable, making choices A and C less appropriate as they lack specificity and measurability.
2. Which statement best describes evidence-based practice?
- A. Reading and analyzing research reports to determine their implementation in nursing practice
- B. Collecting data to evaluate the efficiency of nursing practice in delivering quality care
- C. Monitoring unit practices to ensure adherence to Joint Commission standards
- D. Using the most effective, current, and applicable information to guide nursing care for the best outcomes
Correct answer: D
Rationale: Evidence-based practice involves utilizing the most effective, current, and relevant information to inform nursing care decisions for optimal client outcomes. While research reports and data collection are important components of evidence-based practice, the essence lies in integrating all available information to determine the best course of action. Monitoring compliance with standards, as described in choices A and C, is essential for quality assurance but does not capture the comprehensive nature of evidence-based practice.
3. 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.
4. 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.
5. What is the initial step to take when a patient passes out at the front desk?
- A. Call 911.
- B. Initiate CPR.
- C. Shake the patient and ask if they are okay.
- D. Check for a pulse.
Correct answer: C
Rationale: The correct initial step when a patient passes out at the front desk is to shake the patient gently and ask if they are okay. This step aims to assess the patient's level of responsiveness. Checking for a pulse or initiating CPR should only be done if the patient does not respond to being shaken. Calling 911 can be the next step after assessing the patient's immediate condition and providing necessary assistance.
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