NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. Which of the following is an organizational factor that affects workplace violence directed at nurses?
- A. Clients who have short hospital stays
- B. The presence of security guards
- C. Restricted client areas
- D. Understaffing of nursing personnel
Correct answer: D
Rationale: Understaffing of nursing personnel is a critical organizational factor that can contribute to workplace violence directed at nurses. When there are too few nurses on duty due to understaffing, it can lead to delays in care delivery and inadequate attention to clients' needs. This situation can result in heightened frustration, aggression, or violence from clients or their families towards the nursing staff. On the other hand, the presence of security guards (Choice B) may enhance safety in the workplace and deter violence, making it an incorrect choice. Clients who have short hospital stays (Choice A) and restricted client areas (Choice C) are not directly linked to organizational factors that promote workplace violence against nurses, making them incorrect choices.
2. To properly read a meniscus,
- A. hold the measuring device at eye level and read the bottom of the curve of the liquid level
- B. hold the measuring device at eye level and read the top of the curve of the liquid level where the liquid adheres to the walls of the container.
- C. hold the measuring device at table level and, looking down into the measuring device, read the bottom of the curve of the liquid level.
- D. hold the measuring device at table level and, looking down into the measuring device, read the top of the curve of the liquid level.
Correct answer: A
Rationale: To properly read a meniscus, it is essential to hold the measuring device at eye level to avoid parallax error. Reading the bottom of the curve of the liquid level is correct because the meniscus is the concave or convex curve at the liquid's surface. Choice B is incorrect because reading the top of the curve where the liquid adheres to the walls of the container can lead to inaccurate measurements. Choices C and D are incorrect as they suggest holding the device at table level, which can introduce parallax error and result in an incorrect reading.
3. The abbreviation ac is defined as _____________.
- A. before the meal
- B. with the meal
- C. after the meal
- D. ante cibum
Correct answer: A
Rationale: The correct answer is 'before the meal.' The abbreviation 'ac' is derived from the Latin term 'ante cibum,' which translates to 'before a meal.' Choices B, C, and D are incorrect because 'ac' does not refer to 'with the meal,' 'after the meal,' or 'ante corpis.' It specifically denotes something occurring before a meal, making option A the correct choice in this context.
4. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?
- A. Avoid palpating reportedly “tender” areas as this may cause pain.
- B. Palpate tender areas quickly to minimize patient discomfort.
- C. Initiate the assessment with deep palpation while encouraging the patient to relax and take deep breaths.
- D. Begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch.
Correct answer: D
Rationale: The correct approach is to begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch. This allows the nurse to first assess surface features before proceeding to deeper palpation. Starting with light palpation also helps the patient become more comfortable with being touched, creating a smoother examination experience. Palpating tender areas quickly, as suggested in choice B, can increase patient discomfort. Deep palpation, as in choice C, is typically performed after light palpation to avoid discomfort and ensure proper assessment. Avoiding palpation of tender areas first, as in choice A, helps prevent causing unnecessary pain and should be done towards the end of the assessment.
5. When providing endotracheal suctioning, for how long should the nurse suction the endotracheal tube of an intubated client on a ventilator at a time?
- A. Five seconds or less
- B. Ten seconds or less
- C. At least 30 seconds
- D. No longer than 60 seconds
Correct answer: B
Rationale: When providing endotracheal suctioning, the nurse should suction for no longer than ten seconds at a time. Suctioning for longer than ten seconds may cause hypoxia or bronchospasm. Extended suctioning may also place the client at risk of injury to the bronchial and tracheal structures. Choices C and D suggest prolonged suctioning durations that can lead to adverse effects on the client. Choice A, suctioning for five seconds or less, may not be adequate to clear secretions effectively, making choice B the most appropriate duration for safe and efficient suctioning in this scenario.
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