NCLEX-RN
NCLEX RN Exam Review Answers
1. What is a key principle of patient teaching that must take place to ensure patient safety?
- A. Family members should be present
- B. Teaching must be documented
- C. Understanding must be confirmed
- D. Teaching should be provided by multiple staff members
Correct answer: C
Rationale: A key principle of patient teaching that ensures patient safety is the confirmation of understanding. To ensure patient safety, it is crucial to confirm that the patient comprehends the information provided. This confirmation can be achieved by having the patient repeat back the information or demonstrate understanding through return demonstration. Documenting the patient's understanding is essential to track the effectiveness of the teaching session and ensure that the patient is equipped with the necessary knowledge for their safety. Family members being present or having multiple staff members provide teaching may be beneficial in certain situations, but the primary focus should be on confirming the patient's understanding to enhance safety and promote effective learning.
2. The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?
- A. A 26-year-old woman who had a bowel resection
- B. A 40-year-old man who underwent a hernia repair
- C. A 31-year-old woman with septicemia and who is on a ventilator
- D. A 91-year-old man with Alzheimer's disease recovering from a fall
Correct answer: A
Rationale: When deciding on transferring patients between units in a hospital, it is essential to consider the appropriateness of the patient for the receiving unit. The Women's Health Center typically caters to female patients with gynecological or obstetric conditions that do not require intensive monitoring or specialized care. In this scenario, the most suitable patient for transfer to the Women's Health Center would be the 26-year-old woman who had a bowel resection, as her condition aligns more closely with the services provided in that unit. The other options, including a male patient, a critically ill patient on a ventilator, and an elderly patient with Alzheimer's disease, would not be appropriate for transfer to a Women's Health Center due to the specialized care they require, which may not align with the unit's focus and staffing capabilities.
3. How do technological advances relate to HIPAA?
- A. Technology can expose us to HIPAA violations.
- B. Computers facilitate information sharing.
- C. Computer screens should be visible only to authorized personnel.
- D. Technology enhances HIPAA confidentiality.
Correct answer: A
Rationale: Technology can expose us to HIPAA violations. For instance, leaving a computer screen unattended and visible to unauthorized individuals can result in breaches of patient confidentiality, leading to HIPAA violations. While computers can indeed aid in sharing information, this is not directly related to HIPAA compliance. Ensuring that computer screens are only visible to authorized personnel is a good practice, but it does not address the broader risks and challenges posed by technological advancements in maintaining HIPAA compliance. Therefore, the correct answer is that technology can expose us to HIPAA violations.
4. A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?
- A. Do you mean your boyfriend?
- B. Do you mean your boyfriend?
- C. No one will ever hurt you again.
- D. Tell me more about what happens when he gets angry.
Correct answer: D
Rationale: The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.
5. Which of the following is an example of restorative care?
- A. A nurse teaches a new mother how to breastfeed her infant
- B. A nurse helps a client with developing a bladder-retraining program
- C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
- D. A nurse contacts the family of a client to tell them he will be out of surgery soon
Correct answer: B
Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.
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