NCLEX-RN
NCLEX RN Exam Review Answers
1. The nurse is discussing the need for early diagnosis and treatment of autism spectrum disorder (ASD) with parents of children suspected of having the condition. Which statement should the nurse include?
- A. Early diagnosis and treatment provide the only means for a cure of ASD.
- B. Early diagnosis and treatment gives your child the best chance of becoming a fully functioning adult.
- C. Early diagnosis and treatment provides the best way to ensure that your child can be admitted to an assisted living facility as an adult.
- D. Early diagnosis and treatment prevent your child from developing any other mental condition.
Correct answer: B
Rationale: The correct statement for the nurse to include is that early diagnosis and treatment provide the best chance for the child to become a fully functioning adult. It is important to educate parents that while early intervention can improve outcomes for individuals with ASD, it does not offer a cure but helps in managing symptoms and developing necessary skills. Choice A is incorrect as there is currently no cure for ASD. Choice C is inaccurate as early diagnosis and treatment focus on improving the child's quality of life and independence rather than ensuring admission to an assisted living facility. Choice D is incorrect as early diagnosis and treatment of ASD do not prevent the development of other mental health conditions; however, they can help in identifying and managing such conditions early on.
2. OSHA has very strict standards for hospital employees who may encounter hazardous materials or patients who have been exposed to them. These regulations include all of the following EXCEPT:
- A. Respiratory protection must be provided to all employees who might be exposed.
- B. Training on respiratory protection must be provided.
- C. Employers must provide personal protective equipment to all employees.
- D. All ED personnel must be trained in decontamination procedures.
Correct answer: D
Rationale: OSHA regulations for hospital employees dealing with hazardous materials or exposed patients require respiratory protection for potentially exposed employees, training on respiratory protection, and the provision of personal protective equipment. However, not all ED personnel are required to be trained in decontamination procedures. While all ED staff should have a basic understanding of hazmat situations, specific training in decontamination procedures is only necessary for those who will be directly involved in the decontamination process. Therefore, the correct answer is that all ED personnel must be trained in decontamination procedures, as this is not a mandatory requirement under OSHA regulations for hospital employees who may encounter hazardous materials or exposed patients.
3. Tommy R., your 68-year-old patient, is at risk for falls. He has fallen 3 times in the last month. You should keep Tommy's ______________ in order to prevent him from falling again.
- A. bedside rails up at all times
- B. bed in the low position
- C. call bell within reach
- D. family members in the room at all times
Correct answer: C
Rationale: To prevent falls, it is essential to keep the patient's call bell within reach so they can easily call for help when needed. This allows for timely assistance and can prevent falls. While low beds can reduce the severity of injuries in case of a fall, they do not prevent falls from happening. Having family members in the room at all times is not a realistic or practical solution. Side rails can actually increase the severity of falls as patients may attempt to climb over them, and using side rails as fall prevention is considered a restraint practice that can lead to entrapment and other risks.
4. Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?
- A. A 65-year old male with urine output of 60cc in the past four hours
- B. A 2-month old female with a temperature of 100.6 rectally
- C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
- D. A 4-year old male with an oxygen saturation of 96% on room air
Correct answer: D
Rationale: Clients must meet a certain amount of set criteria before they will be discharged from a healthcare facility. Although guidelines may vary between locations, most healthcare facilities expect clients to have adequate oxygenation, nutrition, and elimination; and be free from fever, vomiting, and significant pain
5. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?
- A. Torticollis, with shortening of the sternocleidomastoid muscle
- B. Craniosynostosis, with premature closure of the cranial sutures
- C. Plagiocephaly, with flattening of one side of the head
- D. Hydrocephalus, with increased head size
Correct answer: A
Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.
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