NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. The most accurate reading for a temperature is done:
- A. Orally
- B. Aurally through a clean canal
- C. Rectally
- D. Axially
Correct answer: B
Rationale: Aural readings are done through the ear canal. The tympanic membrane shares a blood supply with the hypothalamus, the brain area that regulates body temperature. Taking the temperature aurally through a clean canal ensures an accurate reading. Choice A (Orally) is not the most accurate method for temperature measurement as it can be affected by external factors like drinking hot or cold liquids. Choice C (Rectally) is invasive and less practical for routine temperature monitoring. Choice D (Axially) is not a standard method for temperature measurement and may not provide accurate results.
2. Which is the most effective action for controlling the spread of infection?
- A. Thorough hand hygiene
- B. Wearing gloves and masks when providing direct client care
- C. Implementing appropriate isolation precautions
- D. Administering broad-spectrum prophylactic antibiotics
Correct answer: A
Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.
3. Which of the following activities would the nurse perform during the diagnosing phase of the nursing process? Select all that apply.
- A. Collect and organize client information
- B. Analyze data
- C. Identify problems, risks, and client strengths
- D. Develop nursing diagnoses
Correct answer: B
Rationale: During the diagnosing phase of the nursing process, the nurse analyzes the collected data to identify problems, risks, and client strengths, which then leads to developing nursing diagnoses. Collecting and organizing client information is part of the assessment phase, where data is gathered. Developing nursing diagnoses comes after data analysis in the diagnosing phase. Goal setting is a component of the planning phase, which follows the diagnosing phase.
4. Which of the following is an example of an environmental hazard that may put the healthcare professional at risk of injury?
- A. Loud noise from the hospital maintenance system
- B. Airborne powder containing latex
- C. Chemicals containing ethylene oxide
- D. All of the above
Correct answer: D
Rationale: Healthcare professionals, including nurses, are exposed to various environmental hazards that may negatively impact their physical or mental health. Hazards come in several forms, such as loud noise from hospital systems, which can damage hearing; airborne latex powder, leading to allergic reactions; and chemicals like ethylene oxide, a sterilizing agent that can cause cancer. Therefore, all the options listed pose risks to healthcare professionals, making 'All of the above' the correct answer. Choice A, loud noise, is a hazard that can affect hearing health. Choice B, airborne latex powder, can trigger allergic responses. Choice C, chemicals containing ethylene oxide, are hazardous and can lead to serious health issues. Each option represents a distinct environmental risk that healthcare professionals should be aware of and take precautions against.
5. When examining an infant, which area should the nurse examine first?
- A. Ear
- B. Nose
- C. Throat
- D. Abdomen
Correct answer: D
Rationale: When examining an infant, the nurse should start by examining the least-distressing areas first before moving on to more invasive areas. The abdomen is typically the least distressing area to examine, so it should be assessed first. Examining the eye, ear, nose, and throat are considered more invasive and should be saved for last. Therefore, the correct choice is to examine the abdomen first to ensure a comfortable and less distressing examination process for the infant. Choices A, B, and C (Ear, Nose, Throat) are more invasive areas and should be examined after the abdomen.
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