NCLEX-RN
NCLEX RN Exam Preview Answers
1. What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?
- A. Will comply with the treatment prescribed.
- B. Has given up her belief in naturalistic causes of disease.
- C. May also be seeking the assistance of a shaman or medicine man.
- D. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.
Correct answer: C
Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.
2. The UAP who has just been accepted to nursing school says to a client, 'You must be so pleased with your progress.' The nurse later explains to the UAP that this is an example of what type of question?
- A. Close-ended question
- B. Open-ended question
- C. Leading question
- D. Neutral question
Correct answer: C
Rationale: The statement 'You must be so pleased with your progress' is an example of a leading question. Leading questions guide the respondent towards a particular answer or response, potentially biasing the data collected. In this scenario, the UAP's question implies that the client should be pleased with their progress, steering the client's response. Closed-ended questions typically elicit brief factual responses or a 'yes' or 'no.' Open-ended questions encourage clients to provide detailed responses and share their thoughts and feelings freely. Neutral questions do not lead or influence the client's response, allowing for unbiased information gathering.
3. What is the primary purpose of emergency planning?
- A. Comply with the laws of the state.
- B. Comply with the laws of the U.S.
- C. Comply with both state and U.S. laws
- D. Maintain safety
Correct answer: D
Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.
4. A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
- A. A middle-aged client who says, "I took too many diet pills"? and "my heart feels like it is racing out of my chest."?
- B. A young adult who says, "I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?"?
- C. An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 11.
- D. An elderly client who reports having taken a "large crack hit"? 10 minutes prior to walking into the emergency room.
Correct answer: C
Rationale: When assigning a floated nurse from another unit to a client in the emergency department, the goal is to choose a patient with minimal anticipated immediate complications. In this scenario, the adolescent with terminal cancer who has been on pain medications and presents with pinpoint pupils and a relaxed respiratory rate of 11 is the most stable option. These assessment findings indicate opioid toxicity, which, while serious, has the least risk of immediate complications compared to the other clients. Choice A involves a middle-aged client experiencing symptoms of possible cardiac issues due to diet pill overdose, which requires urgent intervention. Choice B presents a young adult with concerning symptoms of potential psychosis or substance withdrawal, requiring immediate attention. Choice D involves an elderly client who recently used crack, posing a high-risk situation that requires prompt evaluation and intervention. Therefore, the correct choice is the adolescent with opioid toxicity, as this client has the least immediate risk of complications among the options provided.
5. The body system that functions to maintain fluid balance, support immunity, and contains the spleen is the:
- A. Lymphatic System
- B. Digestive System
- C. Urinary System
- D. Respiratory System
Correct answer: A
Rationale: The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.
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