NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. Where is the duodenum located in the digestive system?
- A. It is the first part of the small intestine, located immediately after the stomach.
- B. It is the section of the digestive system where the gall bladder delivers bile.
- C. It is the section of the small intestine where the pancreas delivers digestive juices.
- D. None of the above.
Correct answer: D
Rationale: The duodenum is the first part of the small intestine, located immediately after the stomach. It is where the majority of digestion takes place in the gut. The pancreas delivers digestive juices containing amylase and lipase, while the gall bladder delivers bile to aid in the digestion of fats. Choice A incorrectly states that the duodenum is the third section of the small intestine, which is inaccurate. Choice B incorrectly associates the duodenum with the gall bladder, which is not where the duodenum is located. Choice C incorrectly states that the duodenum is where the pancreas delivers digestive juices, which is partly correct but not the main function of the duodenum. Therefore, the correct answer is 'None of the above' as none of the choices accurately describe the location or functions of the duodenum.
2. 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.
3. A client is being transferred from a bed to a wheelchair. Which action is essential to maintain client safety in this situation?
- A. Position the wheelchair at the foot of the bed
- B. Maintain a space of at least 12 inches between the wheelchair and the bed
- C. Place the footplates in the lowest position before transferring the client
- D. Lock both wheels on the wheelchair before moving the client
Correct answer: D
Rationale: When transferring a client from a bed to a wheelchair, it is crucial to prioritize client safety. Locking both wheels on the wheelchair before moving the client is essential as it adds stability and prevents the wheelchair from moving unexpectedly during the transfer process. Placing the wheelchair at the foot of the bed allows for easier transfer, but ensuring the wheels are locked is more critical for safety. Maintaining a 12-inch space between the wheelchair and the bed is not as essential as ensuring wheel locks are engaged. While placing the footplates in the lowest position can enhance client comfort, it is not a safety measure that is as critical as securing the wheelchair by locking its wheels before the transfer.
4. A patient works with a nurse to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action?
- A. Remain silent.
- B. Educate the patient that the outcome is not realistic.
- C. Explore with the patient possible consequences of the outcome.
- D. Formulate an appropriate outcome without the patient's input.
Correct answer: C
Rationale: In this scenario, the nurse should collaborate with the patient rather than impose personal opinions. While the nurse should respect the patient's autonomy, they also have a duty to provide guidance. By exploring possible consequences of the suggested outcome with the patient, the nurse can facilitate a discussion that helps the patient make an informed decision. This approach respects the patient's input while ensuring their well-being. Remaining silent (Choice A) may not address the issue, educating the patient unilaterally (Choice B) may be perceived as dismissive, and formulating an outcome without patient input (Choice D) disregards the patient's autonomy and preferences.
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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