NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. Which of the following is a function of risk management?
- A. To consider the problems that arise if errors happen and their effects on the healthcare environment
- B. To identify how nursing care responds to specific client problems
- C. To view clients as customers and decide what actions will provide a satisfying healthcare experience
- D. To analyze physician-nurse relationships and determine where collaboration efforts can improve
Correct answer: A
Rationale: The function of risk management in healthcare is to assess and address potential risks that could lead to errors and their effects on the healthcare environment. This involves identifying, evaluating, and prioritizing risks to minimize their impact and prevent adverse outcomes. Choice A is correct because it aligns with the core purpose of risk management in healthcare. Choices B, C, and D are incorrect as they do not directly relate to the primary focus of risk management, which is the proactive management of risks to ensure patient safety and quality care.
2. A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?
- A. Delirium
- B. Muscle rigidity
- C. Hypotension
- D. Pinpoint rash
Correct answer: A
Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.
3. Victor, a 43-year-old patient who is HIV positive with a diagnosis of pneumocystis carinii pneumonia (PCP), has been admitted to the hospital. His prognosis is very poor, and his partner, Roger, would like to have a ceremony performed in his room to honor their union in case something happens to Victor, who agrees. What is the most appropriate response to their request?
- A. Inform them that Victor is too ill for a ceremony
- B. Ask the social worker to intervene
- C. Tell them it's against hospital policy
- D. Coordinate with other disciplines to support their request
Correct answer: D
Rationale: The most appropriate and compassionate response is to respect Victor and Roger's relationship and honor their wishes. Coordinating with other disciplines, such as social work, chaplaincy, or patient advocacy, to support their request demonstrates a holistic approach to care. This collaborative effort can facilitate the ceremony and provide emotional support to both Victor and Roger during a challenging time. Upholding their request aligns with the principles of patient-centered care and promotes dignity and respect, as outlined in the ANA Code of Ethics. Informing them that Victor is too ill for a ceremony (Choice A) would dismiss their emotional needs and fail to address their request. Involving the social worker without understanding the specific request (Choice B) may not directly address their desire for a ceremony. Telling them it's against hospital policy (Choice C) disregards the importance of honoring patient preferences and may cause unnecessary distress in an already sensitive situation.
4. A patient with bipolar disorder asks the nurse, "Why did I get this illness? I don't want to be sick."? The nurse would best respond with:
- A. People who develop mental illnesses often had a very traumatic childhood experience.
- B. There is some evidence that contracting a virus during childhood can lead to mental disorders.
- C. Sometimes people with mental illness have an overactive immune system.
- D. We don't fully understand the cause, but mental illnesses do seem to run in the family.
Correct answer: D
Rationale: The correct response is, 'We don't fully understand the cause, but mental illnesses do seem to run in the family.' Current research suggests that while genetics play a role in the development of mental illnesses like bipolar disorder, it is not the sole factor. Environmental influences, life experiences, and other non-genetic factors also contribute significantly to the manifestation of mental disorders. Choices A, B, and C provide incorrect information that is not supported by current research. Traumatic childhood experiences, contracting a virus during childhood, and an overactive immune system are not established causes of bipolar disorder or mental illnesses in general.
5. Which of the following screening tools have been found to have high diagnostic accuracy for screening for intimate partner violence?
- A. Hurt, Insult, Threaten, and Scream (HITS)
- B. Humiliation, Afraid, Rape, and Kick (HARK)
- C. Slapped, Threatened, and Thrown (STaT)
- D. All of the above
Correct answer: D
Rationale: All of the above screening tools, including HITS, HARK, and STaT, have been found to have high diagnostic accuracy for screening intimate partner violence, as per the National Preventive Services Task Force. These tools are effective in identifying current or recent intimate partner violence. While the Partner Violence screen may have some predictive value for future intimate partner violence, the question specifically focuses on screening tools with high diagnostic accuracy, making 'All of the above' the correct choice. Choices A, B, and C are specific validated screening tools for intimate partner violence, each with its own set of questions that have been shown to be effective in identifying individuals experiencing intimate partner violence. Therefore, 'All of the above' is the most comprehensive and accurate choice for this question.
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