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. A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?
- A. Stop the interview at this point and resume later when the client is better able to concentrate
- B. Ask the client, 'Are you seeing something on the ceiling?'
- C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.'
- D. Continue the interview without commenting on the client's behavior
Correct answer: B
Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury. Choices A, C, and D are incorrect. Stopping the interview (choice A) may not address the immediate concern of the hallucination. Providing false reassurance (choice C) or ignoring the behavior (choice D) does not actively address the client's altered perception of reality.
3. When a mother is inquiring about her child's ability to potty train, what is the most critical aspect of toilet training?
- A. The age of the child
- B. The child's ability to understand instructions
- C. The overall mental and physical abilities of the child
- D. Consistent attempts with positive reinforcement
Correct answer: C
Rationale: The most critical aspect of toilet training is the overall mental and physical abilities of the child. While age can play a role, it is not the sole determining factor. Understanding instructions is important but may not be the most critical aspect. Consistent attempts with positive reinforcement can be helpful, but without considering the child's abilities, it may not lead to successful potty training.
4. Which of the following statements best describes compartment syndrome?
- A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
- B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
- C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
- D. An injury causes pain and swelling of the median plantar nerve.
Correct answer: B
Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.
5. What information should be collected when assessing the health status of a community?
- A. Air pollution levels
- B. Number of health food stores
- C. Most common causes of death
- D. Education level of the individuals
Correct answer: C
Rationale: When assessing the health status of a community, it is crucial to gather data on various health measures such as the most common causes of death. This information helps in understanding the prevalent health issues within the community. Factors like air pollution levels, the number of health food stores, and the education level of individuals are important community aspects but do not directly reflect the health status of the community. Therefore, the correct answer is to collect data on the most common causes of death as it provides insights into the major health concerns affecting the community.
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