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. Which of these devices is considered a protective device, rather than a restraint?
- A. A mitten on the hands to prevent scratching
- B. A mitten on the hands to prevent the person from pulling their IV out
- C. A side rail to prevent the patient from falling
- D. A soft wrist restraint to prevent the patient from pulling their IV tubing
Correct answer: A
Rationale: A mitten on the hands to prevent scratching is considered a protective device because its primary purpose is to protect the patient from harming themselves by scratching. It does not restrict the patient's movement. Choice B, a mitten on the hands to prevent the person from pulling their IV out, is considered a restraint as it limits the patient's movement. Choice C, a side rail to prevent the patient from falling, is also a protective device as it aims to keep the patient safe by providing support and preventing falls. Choice D, a soft wrist restraint to prevent the patient from pulling their IV tubing, is a type of restraint as it restricts the patient's movement to prevent them from interfering with medical equipment.
3. A victim of a gunshot wound to the abdomen has been admitted to the hospital, accompanied by a police officer. When questioned, the officer states that the patient is a suspect in a homicide, which occurred as part of the same incident. A small child was killed as the result of a stray bullet. The patient is combative, yells that he's in pain and demands medication. What is your most appropriate response?
- A. Tell him you'll take care of him after your other patients
- B. Reinforce restraints
- C. Perform a pain assessment and administer pain medication
- D. Ask the officer for more details of the incident
Correct answer: C
Rationale: The most appropriate and caring response is to perform a pain assessment and administer the pain medication that has been ordered. Regardless of personal feelings about any given situation, the nurse's responsibility is to provide unbiased, appropriate, and supportive care, as stated in the American Nurses Association (ANA) Code of Ethics. Choice A is not appropriate as it disregards the patient's immediate need for pain relief. Choice B may escalate the situation and is not the priority in this case. Choice D is not the immediate action needed to address the patient's pain and distress.
4. What is the purpose of performing quality control?
- A. Create a paper trail to show that the laboratory is compliant with OSHA standards for quality control.
- B. Improve the odds that the results reported for any given test are as accurate and reliable as possible.
- C. Be required by law to be part of a quality assurance program.
- D. All of the above
Correct answer: B
Rationale: The primary purpose of performing quality control is to enhance the accuracy and reliability of test results. Quality controls are crucial for ensuring the reliability of each analyte tested. While quality control is not mandated by specific laws, accrediting bodies often require it to maintain accreditation. Creating a paper trail and legal requirements are not the primary objectives of quality control, making choices A and C incorrect. Therefore, the correct answer is to improve the accuracy and reliability of reported test results.
5. A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?
- A. External light sources may cause falsely high oximetry values
- B. A bright light in the client's face may cause a low pulse oximetry
- C. External light sources may cause falsely low oximetry values
- D. The client needs a dark and quiet room to recover and maintain proper oxygenation
Correct answer: A
Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.
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