NCLEX-RN
NCLEX RN Exam Review Answers
1. The client is receiving an MAOI. Which foods should the nurse caution the client to avoid?
- A. Pork, spinach, and fresh oysters
- B. Milk, grapes, and meat tenderizers
- C. Cheese, beer, and products with chocolate
- D. Leafy green vegetables, fresh apples, and ice cream
Correct answer: C
Rationale: The correct answer is C. When a client is receiving a monoamine oxidase inhibitor (MAOI), they should avoid foods high in tyramine to prevent a hypertensive crisis. Cheese, beer, and products with chocolate are rich in tyramine and can interact with MAOIs, leading to a dangerous rise in blood pressure. Choices A, B, and D do not contain high levels of tyramine and are not typically restricted when taking MAOIs.
2. A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?
- A. Contact the physician to amend the order for the client
- B. Document an account of the situation to ensure adequate coverage of details
- C. Consult with the medical ethics committee to determine a safe and workable solution
- D. Speak with the chief nursing officer to change the policy governing this situation
Correct answer: A
Rationale: In this type of situation, the first action of the nurse should be to address the immediate needs of the client by requesting the physician to make a change based on the circumstances. The primary concern is to ensure the client's well-being and honor the family's wishes, even if it means deviating from standard protocols. While documentation (Choice B) and consulting with higher authorities like the medical ethics committee (Choice C) may be necessary at a later stage, the initial step is to take action to meet the client's needs promptly. Speaking with the chief nursing officer to change the policy (Choice D) is not the most immediate or practical step in this situation, as the focus should be on the client's current care needs.
3. A nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:
- A. Psychological abuse
- B. Abandonment
- C. Material exploitation
- D. Physical abuse
Correct answer: A
Rationale: The correct answer is A: Psychological abuse. This behavior is classified as psychological abuse, which harms another person through words or threats. The nursing assistant's actions of yelling, making threats, and using food as a form of control fall under psychological abuse. Abandonment (choice B) refers to deserting or leaving a client without care, which is not the case in the scenario. Material exploitation (choice C) involves taking advantage of a person's assets or resources for personal gain, which is not evident here. Physical abuse (choice D) involves causing physical harm, which is not the primary issue in this situation. Therefore, the most appropriate classification for the behavior described in the scenario is psychological abuse.
4. Examples of preservation of self-integrity include all of the following except:
- A. Using assistive equipment to move bariatric clients
- B. Participating in wellness programs
- C. Accepting the challenge of caring for clients with oppositional beliefs or practices
- D. Using hand hygiene and personal protective equipment
Correct answer: C
Rationale: Preservation of self-integrity involves actions that support the nurse's well-being and ethical standards. Using assistive equipment to move bariatric clients and practicing hand hygiene and personal protective equipment are essential aspects of maintaining physical health and safety, contributing to self-care. Participating in wellness programs further enhances self-care by promoting overall well-being. However, accepting the challenge of caring for clients with oppositional beliefs or practices can be emotionally taxing and may compromise a nurse's self-integrity if it leads to significant moral distress or ethical conflicts. In such situations, it is important for nurses to prioritize their well-being and ethical values by seeking alternative solutions or support.
5. A client is receiving education on cholesterol. Which of the following statements from the client indicates the need for further teaching?
- A. I would like my HDL levels to be over 50.
- B. It is better for me to have high HDL levels and low LDL levels.
- C. It is better for me to have high LDL levels and low HDL levels.
- D. My goal is to get my total cholesterol below 200.
Correct answer: C
Rationale: The correct answer is, 'It is better for me to have high LDL levels and low HDL levels.' This statement indicates a need for further teaching because high LDL levels contribute to atherosclerosis, while high HDL levels can protect against heart disease. The client should understand the importance of lowering LDL levels and increasing HDL levels to maintain good heart health. Choice A is correct as desiring HDL levels over 50 is a positive goal. Choice B is correct as it reflects the ideal scenario of high HDL and low LDL levels. Choice D is correct as a total cholesterol below 200 is a common goal for heart health. Therefore, Choice C is incorrect as it suggests an opposite and unhealthy relationship between LDL and HDL levels.
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