NCLEX NCLEX-RN
NCLEX RN Exam Preview Answers
1. What does an individual who believes in the magicoreligious theory of illness and disease think is the cause of illness?
- A. Germs and viruses
- B. Supernatural forces
- C. Eating imbalanced (hot/cold) foods
- D. Imbalance within his or her spiritual nature
Correct answer: Supernatural forces
Rationale: Individuals who adhere to the magicoreligious theory of illness and disease attribute the cause of illness to supernatural forces. In this perspective, the world is perceived as governed by supernatural forces that influence the well-being of individuals. The belief is that these forces can bring about both good and evil outcomes. Choices A, C, and D are incorrect. Germs and viruses are associated with the biomedical theory of illness. Eating imbalanced hot or cold foods is linked to the yin/yang naturalist theory. Imbalance within one's spiritual nature is not a recognized cause of illness in any of the established theories of illness.
2. Which of the following measures would be appropriate for a nurse to teach the parent of a nine-month-old infant about diaper dermatitis?
- A. Use only cloth diapers that are rinsed in bleach
- B. Do not use occlusive ointments on the rash
- C. Use commercial baby wipes with each diaper change
- D. Discontinue a new food that was added to the infant's diet just prior to the rash
Correct answer: Discontinue a new food that was added to the infant's diet just prior to the rash
Rationale: Diaper dermatitis can be caused by various factors, one of which includes introducing new foods to the infant's diet. Discontinuing the new food that was added just before the rash can help identify and eliminate the potential cause. Options A and C are not directly related to addressing the cause of diaper dermatitis. While using cloth diapers rinsed in bleach may be a preventive measure for diaper dermatitis, it is not addressing a specific cause. Option B, advising against using occlusive ointments on the rash, may actually be beneficial in managing diaper dermatitis, but it does not address the cause of the condition.
3. A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?
- A. Knife fight
- B. Auto accident
- C. Sunburn
- D. Fungal infection
Correct answer: Sunburn
Rationale: Vesicles are fluid-filled blisters. In the context of the upper torso, the presentation of vesicles suggests a second-degree sunburn. Sunburn can cause blistering, leading to the formation of vesicles. Choice A, 'Knife fight,' does not align with the presentation of vesicles on the upper torso due to trauma. Choice B, 'Auto accident,' is more likely to cause abrasions or bruises rather than vesicles. Choice D, 'Fungal infection,' typically presents with other symptoms such as redness, itching, or scaling, but not vesicles on the upper torso.
4. You are caring for a Hispanic patient who is scheduled for surgery in the morning. A member of the surgery staff is in a hurry when she visits the patient to obtain surgical consent. You know that the patient speaks limited English and can see that he does not really understand what's being said. What is the most appropriate next action?
- A. Call a family member to interpret
- B. Consult the hospital translator to assist
- C. Allow the consent to be signed
- D. Ask the staff member to come back later
Correct answer: Consult the hospital translator to assist
Rationale: Consulting the hospital translator is the most reliable means of ensuring accuracy in the information that the patient is receiving. Family members can be helpful, but they may have difficulty understanding the medical procedures well enough to explain them accurately and may misinterpret the message. Relying on family members could lead to misunderstandings or miscommunication. Allowing the consent to be signed without ensuring the patient's full understanding could pose risks to the patient's well-being. Asking the staff member to come back later delays the essential communication process needed before surgery. Therefore, consulting the hospital translator is the best course of action to ensure clear and accurate communication, especially in critical healthcare decisions like surgical consent.
5. A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?
- A. Start a peripheral IV line to administer any necessary sedative drugs.
- B. Position the patient sitting upright on the edge of the bed and leaning forward.
- C. Obtain a collection device to hold a reasonable amount of pleural fluid for extraction.
- D. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
Correct answer: Position the patient sitting upright on the edge of the bed and leaning forward.
Rationale: The correct action for the nurse to take in preparing a patient for a thoracentesis is to position the patient sitting upright on the edge of the bed and leaning forward. This position helps fluid accumulate at the lung bases, making it easier to locate and remove. Sedation is not usually required for a thoracentesis, so starting an IV line for sedative drugs is unnecessary. Additionally, there are no restrictions on oral intake before the procedure since the patient is not sedated or unconscious. A large collection device to hold 2 to 3 liters of pleural fluid at one time is excessive as usually only 1000 to 1200 mL of pleural fluid is removed to avoid complications like hypotension, hypoxemia, or pulmonary edema. Therefore, the correct choice is to position the patient upright for the procedure.
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