NCLEX NCLEX-RN
NCLEX RN Exam Preview Answers
1. 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: A connection with something larger than oneself and belief in transcendence
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.
2. When are manual hematocrits done?
- A. to monitor anemia
- B. by using a microhematocrit tube.
- C. to measure the percentage of plasma to cells.
- D. All of the above.
Correct answer: All of the above.
Rationale: Manual hematocrits are performed to monitor anemia, which involves measuring the percentage of red blood cells in the blood. The process involves collecting blood in a microhematocrit tube, then centrifuging it to separate the plasma from the cells. By measuring the ratio of plasma to cells, healthcare providers can assess the patient's hematocrit level. Therefore, all the provided options are correct as they collectively describe the purpose and procedure of manual hematocrits.
3. When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?
- A. ''Tell me about your typical day before you were diagnosed with chronic lung disease.''
- B. ''Smoking and not doing the exercises will make your lung disease continue to get worse.''
- C. ''I can’t make you stop doing what you are doing, and it’s your choice to be sick or well.''
- D. ''Your shortness of breath is probably because of your smoking and not doing the exercises.''
Correct answer: ''Tell me about your typical day before you were diagnosed with chronic lung disease.''
Rationale: Asking the client to describe a typical day is the best response. More data are needed about the client’s usual activities of daily living so that the plan can be adapted to the client’s preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client’s behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client’s dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.
4. The nurse is preparing to care for an infant who has esophageal atresia with tracheoesophageal fistula. Surgery is scheduled to be performed in 1 hour. Intravenous fluids have been initiated, and a nasogastric (NG) tube has been inserted by the primary healthcare provider. The nurse plans care, knowing that which intervention is of highest priority during this preoperative period?
- A. Monitor the temperature.
- B. Monitor the blood pressure.
- C. Reposition the infant frequently.
- D. Aspirate the NG tube every 5 to 10 minutes.
Correct answer: Aspirate the NG tube every 5 to 10 minutes.
Rationale: Esophageal atresia with tracheoesophageal fistula is a critical neonatal surgical emergency. The highest priority intervention during the preoperative period is to aspirate the NG tube every 5 to 10 minutes to keep the proximal pouch clear of secretions and prevent aspiration. This is crucial in reducing the risk of gastric secretions entering the lungs. Repositioning the infant frequently is not as critical as ensuring the NG tube is aspirated. Monitoring the temperature and blood pressure are important nursing interventions but are not the highest priority in this situation. It is essential to prioritize airway protection and prevent aspiration in this neonate undergoing urgent surgical intervention.
5. A neonate born at 32 weeks’ gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit (NICU). When would the nurse take the neonate’s mother to visit the infant?
- A. When the infant’s condition has stabilized
- B. When the infant is out of immediate danger
- C. When the primary health care provider has provided written permission
- D. When the mother is well enough to be taken to the NICU
Correct answer: When the mother is well enough to be taken to the NICU
Rationale: The mother should see her infant as soon as possible to acknowledge the reality of the birth and begin bonding. Delaying the visit may impede maternal-infant bonding. The timing of the mother's visit should be based on her physical and emotional readiness, not solely on the infant's condition or the need for written permission. The nurse can independently facilitate the mother's visit without requiring a prescription from the primary healthcare provider.
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