NCLEX NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. The parents of a newborn with a cleft lip are concerned and ask the nurse when the lip will be repaired. With which statement should the nurse respond?
- A. Cleft lip cannot be repaired.
- B. Cleft-lip repair is usually performed by 6 months of age.
- C. Cleft-lip repair is usually performed during the first months of life.
- D. Cleft-lip repair is usually performed between 6 months and 2 years.
Correct answer: Cleft-lip repair is usually performed during the first months of life.
Rationale: Cleft-lip repair is typically performed during the first few months of life to address functional and cosmetic concerns at an early stage. Early repair can enhance bonding and facilitate feeding. While revisions may be necessary later on, addressing the cleft lip early is essential. Option A is incorrect as cleft lip repair is a common surgical procedure. Option B is incorrect as repair is typically done earlier than 6 months for better outcomes. Option D is incorrect as the usual timing for repair is within the first months of life, not between 6 months and 2 years.
2. A college athlete sustained a complete transection of the spinal cord while practicing on a trampoline. The health care provider explained that return of function to the lower extremities is not likely. Two weeks later, the client verbalizes the need to practice for an upcoming tournament. Which conclusion would the nurse make about the client’s statement?
- A. Exhibiting denial
- B. Verbalizing a fantasy
- C. No longer able to adapt
- D. Motivated to recover mobility
Correct answer: Exhibiting denial
Rationale: The correct answer is 'Exhibiting denial.' Denial is a common defense mechanism when facing a serious health issue. The individual rejects the existence of the problem due to the overwhelming anxiety and emotional distress it causes. In this case, the athlete's desire to practice for an upcoming tournament despite being informed about the unlikely return of lower extremity function indicates denial of the severity of their condition. Choice B, 'Verbalizing a fantasy,' is incorrect as a fantasy involves creating imagined events to fulfill unconscious wishes, which is not evident here. Choice C, 'No longer able to adapt,' is incorrect because the client is actually demonstrating a maladaptive coping mechanism by denying the reality of their situation. Choice D, 'Motivated to recover mobility,' is incorrect as the client's goal of practicing for a tournament does not align with the realistic expectation of recovering mobility after a complete spinal cord transection.
3. When observing an infant lying quietly in the bassinet with eyes open wide, what action should the nurse take in response to the infant’s behavior?
- A. Brightening the lights in the room
- B. Encouraging the mother to talk to her baby
- C. Wrapping and then turning the infant to the side
- D. Beginning physical and behavioral assessments
Correct answer: Encouraging the mother to talk to her baby
Rationale: When an infant is lying quietly in a bassinet with eyes open wide, it indicates a quiet, alert state. This state is optimal for infant stimulation and interaction. Bright lights can be disturbing to newborns and may disrupt the mother-infant interaction. Wrapping and turning the infant to the side is typically done for a sleeping infant. While physical and behavioral assessments are important, in this scenario, the priority is to encourage mother-infant bonding and communication, as it is a valuable opportunity for interaction and stimulation.
4. The healthcare professional is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?
- A. Turgor
- B. Texture
- C. Density
- D. Consistency
Correct answer: C: Density
Rationale: Percussion is a technique used to assess the density of underlying organs by producing sounds that help determine their location and size. Turgor, texture, and consistency are primarily assessed through palpation, not percussion. Turgor refers to skin elasticity, texture pertains to the feel of the tissue surface, and consistency relates to the firmness or resistance of the tissue.
5. What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?
- A. Ask where the client obtained the alcohol.
- B. Locate the alcoholic substance.
- C. Convey empathy and support to the client.
- D. Document the client's drinking behavior.
Correct answer: Locate the alcoholic substance.
Rationale: The initial action should be to locate the alcoholic substance. The nurse needs to find and remove the substance to prevent the client or others from consuming more alcohol. Asking where the client obtained the alcohol is not the priority; the focus is on ensuring the client's safety. Conveying empathy and support is essential but should not be the first action in this scenario. Documenting the client's drinking behavior can be done after ensuring immediate safety measures are in place.
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