NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. When a patient is standing in anatomical position, where are their feet?
- A. Facing forward with the toes spread open
- B. Facing out to the sides to open the hips
- C. Side by side and facing forward; toes resting comfortably
- D. The feet are pointed inward.
Correct answer: B
Rationale: When a person is standing in anatomical position, their feet are side by side, and they are facing forward with the toes pointing out to the sides to open the hips. This position allows for proper alignment of the body for anatomical reference. Choice A is incorrect because the feet should not be spread open, but rather side by side. Choice C is incorrect as it does not mention the correct positioning of the feet. Choice D is incorrect as the feet should not be pointed inward, but rather facing out to the sides to open the hips.
2. A second-year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most significant action that the nursing student should take?
- A. Immediately see a social worker
- B. Start prophylactic AZT treatment
- C. Start prophylactic Pentamidine treatment
- D. Seek counseling
Correct answer: B
Rationale: Starting prophylactic AZT treatment is the most critical intervention in this scenario. Azidothymidine (AZT) is an antiretroviral medication used to prevent and treat HIV/AIDS by reducing the replication of the virus. Post-exposure prophylaxis (PEP) for HIV involves taking medication to suppress the virus and prevent infection after exposure. PEP should be initiated within 72 hours of potential HIV exposure to be effective. Seeking treatment quickly is crucial to enhance its effectiveness. Seeing a social worker (Choice A) may be helpful for emotional support but is not the immediate priority. Pentamidine treatment (Choice C) is not indicated for post-exposure prophylaxis for HIV. Seeking counseling (Choice D) is important for the nursing student's emotional well-being but does not address the urgent need for post-exposure prophylaxis to prevent HIV transmission.
3. Penny Thornton has had a stroke, or CVA, and is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be providing Penny with these assistive devices?
- A. A physical therapist
- B. A speech therapist
- C. A social worker
- D. An occupational therapist
Correct answer: D
Rationale: An occupational therapist is the healthcare professional responsible for assessing the needs of individuals, like Penny, regarding assistive devices that aid them in their daily activities. In this case, assistive devices for eating, such as weighted plates and specialized utensils, are crucial for helping Penny regain independence in feeding herself. Physical therapists focus more on mobility and movement, speech therapists on communication and swallowing disorders, and social workers on providing emotional and social support. Therefore, the correct choice is the occupational therapist as they specialize in activities of daily living and promoting independence.
4. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?
- A. Respirations should be counted for 1 full minute.
- B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
- C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
- D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.
Correct answer: A
Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.
5. When is a physician likely to assess turgor?
- A. When iron deficiency is suspected.
- B. When heart and lung issues are suspected.
- C. When dehydration is suspected.
- D. None of the above.
Correct answer: C
Rationale: Skin turgor is assessed when dehydration is suspected. To evaluate skin turgor, a physician pinches the skin and observes how quickly it returns to its normal position. If the skin stays folded for an extended period, it indicates dehydration. Assessing turgor helps determine a patient's hydration status. Choice A is incorrect because skin turgor is not used to assess iron deficiency. Choice B is incorrect as turgor is not related to heart and lung issues, but rather hydration status. Choice D is incorrect as turgor assessment is relevant when dehydration is suspected.
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