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 the following interventions is necessary before insertion of an arterial line into the radial artery?
- A. Ensure that the client does not need surgery
- B. Assess the client's grip strength
- C. Perform an Allen test
- D. Check a serum potassium level
Correct answer: C
Rationale: Before inserting an arterial line into the radial artery, it is crucial to perform an Allen test. The Allen test assesses the collateral circulation to the hand by compressing both the radial and ulnar arteries. By occluding the radial artery and releasing the ulnar artery, the nurse can check if the ulnar artery can adequately supply blood to the hand if the radial artery is cannulated. This step ensures that there is adequate circulation to the hand post-insertion of the arterial line. Choice A, ensuring that the client does not need surgery, is not directly related to the insertion of an arterial line and is not a necessary step before the procedure. Choice B, assessing grip strength, is not specific to the vascular status of the hand and does not provide information about the adequacy of collateral circulation. Choice D, checking a serum potassium level, is unrelated to the assessment of radial artery patency and collateral circulation, which are the primary concerns before arterial line insertion.
3. Which of the following is an example of low health literacy skills?
- A. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
- B. A client cannot read an admission form to sign it
- C. A nurse cannot calculate the correct IV rate for Ringer's lactate
- D. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
Correct answer: B
Rationale: Low health literacy skills are exemplified by an individual's inability to comprehend health-related information. In this scenario, a client's inability to read an admission form to sign it indicates low health literacy. This lack of understanding can hinder their ability to make informed decisions about their healthcare. The other choices involve healthcare professionals and their knowledge or skills, not the health literacy of individuals seeking care.
4. A client has started sweating profusely due to intense heat. His overall luid volume is low and he has developed electrolyte imbalance. This client is most likely suffering from:
- A. Malignant hyperthermia
- B. Heat exhaustion
- C. Heat stroke
- D. Heat cramps
Correct answer: B
Rationale: Heat exhaustion occurs when a person has enough diaphoresis that he becomes dehydrated. Intense sweating can cause both luid and electrolyte imbalances. Untreated heat exhaustion can lead to heat stroke, which results in organ damage, loss of consciousness, or death.
5. A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?
- A. Stop the interview at this point and resume later when the client is better able to concentrate
- B. Ask the client, 'Are you seeing something on the ceiling?'
- C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.'
- D. Continue the interview without commenting on the client's behavior
Correct answer: B
Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury. Choices A, C, and D are incorrect. Stopping the interview (choice A) may not address the immediate concern of the hallucination. Providing false reassurance (choice C) or ignoring the behavior (choice D) does not actively address the client's altered perception of reality.
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