NCLEX-RN
NCLEX RN Exam Preview Answers
1. During a heritage assessment, which question is most appropriate for the nurse to ask?
- A. "Do you smoke?"?
- B. "What is your religion?"?
- C. "Do you have a history of heart disease?"?
- D. "How many years have you lived in the United States?"?
Correct answer: D
Rationale: During a heritage assessment, it is crucial for the nurse to ask questions related to a person's country of ancestry, years in the United States, cultural practices, beliefs, and values. By asking about the number of years lived in the United States, the nurse can gain insights into the individual's cultural background and heritage. Options B, C, and A are not directly related to assessing heritage. Asking about religion only addresses one aspect of heritage, while smoking history and health history do not provide a comprehensive view of a person's heritage.
2. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?
- A. This too shall pass.
- B. Take the child immediately to the ER
- C. Contact the Poison Control Center quickly
- D. Give the child syrup of ipecac
Correct answer: C
Rationale: In situations where a child has ingested a potentially harmful substance, contacting the Poison Control Center quickly is crucial. The Poison Control Center can provide specific guidance tailored to the child's situation, which can include whether immediate medical attention is necessary or if any actions need to be taken at home. Option A, 'This too shall pass,' is not appropriate as it dismisses the seriousness of the situation. Option B, 'Take the child immediately to the ER,' may not always be the best course of action without guidance from experts. Option D, 'Give the child syrup of ipecac,' is outdated advice and not recommended as a first response to poisoning incidents.
3. Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness liquids for her. Water is not a honey thickness liquid. It is much thinner. What should you do?
- A. Tell the resident that she cannot have water.
- B. Give her applesauce instead of the water.
- C. Tell Cheryl that she is NPO until midnight.
- D. Thicken the water and give it to her.
Correct answer: D
Rationale: You can give Cheryl the water that she has requested; however, since water is not a honey-thick liquid as ordered by the doctor, you must thicken it with a commercial thickener before giving it to her. This will ensure that the water is at the appropriate consistency for her swallowing disorder. Choices A, B, and C are incorrect: A) Telling the resident she cannot have water is not the best course of action without attempting to modify it first. B) Giving her applesauce instead of water does not address the specific request for water. C) Placing Cheryl on NPO status until midnight is unnecessary and does not address her immediate request for water.
4. What action by the nurse is appropriate when examining a 16-year-old male teenager?
- A. Discuss health teaching with the teenager to promote wellness.
- B. Ask the parent to step out of the room during the history and physical examination to respect the teenager's privacy.
- C. Use age-appropriate communication when speaking to the teenager to ensure understanding.
- D. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
Correct answer: D
Rationale: During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.
5. Who is most likely to arrange the discharge of a patient to their own home, a nursing home, or an assisted living facility?
- A. A physical therapist
- B. A speech therapist
- C. A social worker
- D. An occupational therapist
Correct answer: C
Rationale: Social workers play a crucial role in arranging patient discharges to suitable facilities. They collaborate with healthcare professionals to ensure that patients are transitioned to the most appropriate setting post-hospitalization. Social workers focus on the holistic needs of patients, including their social and emotional well-being, to facilitate a smooth continuum of care. Choices A, B, and D do not typically have the primary responsibility for arranging patient discharges to various facilities.
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