NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. Who owns a patient's x-rays?
- A. The patient
- B. The doctor
- C. The facility that performed the procedure
- D. None of the above
Correct answer: C
Rationale: X-rays are typically owned by the facility that conducts the procedure, not the patient or the doctor. The facility that performs the procedure is responsible for maintaining and storing the x-rays as part of the patient's medical records. The patient does not own the x-rays since they are part of their medical record and not a physical possession. The doctor also does not own the x-rays as they are generated as a result of the medical procedure conducted at the facility, making choice C the correct answer.
2. Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?
- A. Taking a health history and performing a physical exam prior to the procedure
- B. Instructing the client about how to care for his colostomy stoma
- C. Developing goals that state the client will ambulate three times a day
- D. Determining that the client may need more support at home after dismissal
Correct answer: B
Rationale: The intervention stage of the individualized nursing care plan is where the nurse provides care, treatments, or education to help the client meet the devised outcomes. Instructing the client about how to care for his colostomy stoma is the correct example of an intervention as it directly involves providing education and guidance to the client on post-operative care. This intervention supports the process of helping the client meet the outcomes designed for this case, which is to enable the client to properly care for his colostomy after a bowel resection. The other options do not directly involve interventions aimed at assisting the client in meeting the specific care needs related to the colostomy procedure.
3. A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?
- A. Massaging the reddened areas
- B. Performing range of motion exercises
- C. Administering antithrombotics as ordered
- D. Feeding the client a high-carbohydrate diet
Correct answer: B
Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.
4. A patient with Addison's disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended?
- A. A diet high in grains
- B. A diet with adequate caloric intake
- C. A high protein diet
- D. A restricted sodium diet
Correct answer: D
Rationale: For a patient with Addison's disease, a restricted sodium diet is not recommended. These patients require normal dietary sodium to prevent excess fluid loss. Patients with primary adrenal insufficiency (Addison disease) should have ample access to salt because of the salt wasting that occurs if their condition is untreated. Therefore, a diet high in grains, a diet with adequate caloric intake, and a high protein diet are all recommended for patients with Addison's disease to support their nutritional needs and overall health. However, restricting sodium can be detrimental for these patients due to the nature of their condition.
5. Becky is a 17-year-old type I diabetic who has been admitted for her third episode of diabetic ketoacidosis (DKA) since being diagnosed last year. She states that she hates feeling different from her friends and refuses to take her insulin as recommended. What would be the most helpful action for Becky?
- A. Scolding her for not taking her insulin
- B. Recommending that she use an insulin pump
- C. Contacting the local support group for diabetic teens
- D. Telling her parents they must provide more strict oversight
Correct answer: C
Rationale: Contacting the local support group for diabetic teens would be the most helpful action for Becky. By reaching out to see if another diabetic teenager could provide support, Becky would have the opportunity to connect with someone in her peer group who faces similar challenges. This connection can help reduce her sense of isolation and the feeling of being 'different.' Choice A, 'Scolding her for not taking her insulin,' is inappropriate and could further alienate Becky. It does not address the underlying emotional issues driving her behavior. Choice B, 'Recommending that she use an insulin pump,' does not directly address Becky's emotional struggle with feeling different from her friends. While an insulin pump may be a helpful tool, it does not tackle the root cause of her non-compliance. Choice D, 'Telling her parents they must provide more strict oversight,' focuses on imposing stricter control without addressing Becky's emotional needs or offering peer support, which may not be effective in improving her insulin adherence in the long term.
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