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: B
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 would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?
- A. A person of small stature is at increased risk for injury from entrapment.
- B. A history of a previous fall from a bed with raised side rails is significant.
- C. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails.
- D. Creative use of alternative measures indicates respect for the patient's dignity.
Correct answer: A
Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.
3. A healthcare professional is preparing to administer a dose of platelets to a client. Which of the following actions must the healthcare professional perform before giving the platelets?
- A. Start an IV of 0.9% Normal Saline to administer with the platelets
- B. Ensure the container with the platelets is intact and not damaged
- C. Verify the client's identity using two unique identifiers
- D. Check the client's chart to ensure no contraindications to platelet transfusion
Correct answer: B
Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.
4. 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.
5. What is the primary route of transmission of MRSA?
- A. Shared needles
- B. Hands of healthcare workers
- C. Items in the healthcare environment
- D. Blood transfusions
Correct answer: B
Rationale: The correct answer is 'Hands of healthcare workers.' MRSA is primarily transmitted via the unwashed hands of healthcare workers who can carry the Staphylococcus aureus bacterium from one patient to another. Shared needles, items in the healthcare environment, and blood transfusions are not the main routes of transmission for MRSA. Shared needles can transmit bloodborne pathogens, items in the healthcare environment can harbor bacteria but are not the primary mode for MRSA, and blood transfusions are not a common route for MRSA transmission.
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