NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. Which of the following statements is true regarding non-profit organizations?
- A. They are located in various areas, not specifically poor or rural ones.
- B. They are mandated to care for people, even if clients are unable to pay for services.
- C. The money they receive for services is reinvested back into their own business to further develop services.
- D. They are not referred to as proprietary organizations.
Correct answer: B
Rationale: Non-profit organizations are entities that operate for a social cause or public benefit, and they do not distribute profits to owners or shareholders. They are not limited to being located in poor or rural areas; they can be found in various locations. One key characteristic of non-profits is that they are obligated to provide services, regardless of a client's ability to pay. This ensures that essential services are accessible to all individuals in need. The statement 'The money they receive for services is reinvested back into their own business to further develop services' is correct. Non-profit organizations reinvest any surplus funds back into their operations to enhance the services they provide. The statement 'They are not referred to as proprietary organizations' is correct because proprietary organizations are typically for-profit entities, not non-profit ones.
2. Which action represents the evaluation stage of the plan of care?
- A. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation
- B. The nurse assesses the client's vital signs and asks about symptoms
- C. The nurse determines that the client is not meeting his set outcomes and makes revisions
- D. The nurse discusses the client's health history
Correct answer: C
Rationale: The correct answer is C. The evaluation stage of the nursing process involves reviewing the assessments, diagnoses, and interventions given to the client and then determining if the client is meeting expected outcomes. In this scenario, the nurse is assessing whether the client is meeting the outcomes set for their care plan and making revisions as needed. Choice A is incorrect as assigning a nursing diagnosis is part of the nursing diagnosis phase, not the evaluation phase. Choice B represents the assessment phase of the nursing process, not the evaluation phase. Choice D involves discussing the client's health history, which is more aligned with the assessment phase rather than the evaluation phase.
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. During an adolescent examination, the nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?
- A. Spinal flexibility
- B. Leg length disparity
- C. Hypostatic blood pressure
- D. Scoliosis
Correct answer: D
Rationale: The correct answer is scoliosis. During the assessment for scoliosis, the nurse asks the adolescent to bend forward at the waist with arms hanging freely to observe for any lateral deviation of the spine, uneven rib levels, or asymmetry. This assessment is a routine part of an adolescent examination, especially in females, as scoliosis is more common in this population. Choices A, B, and C are incorrect. Spinal flexibility is usually assessed through different maneuvers, leg length disparity is evaluated by measuring the length of the legs, and hypostatic blood pressure refers to a decrease in blood pressure due to immobility.
5. Which example best describes a nurse who exhibits moral courage?
- A. A nurse feels angry when a parent refuses important treatment for his child.
- B. A nurse considers seeking help for depression when she feels she cannot meet the needs of her clients in the oncology unit.
- C. A nurse contacts a physician for further orders when he fails to order comfort measures for a client with a terminal illness.
- D. A nurse is frustrated when the laboratory is slow in responding to an order for a stat blood glucose.
Correct answer: C
Rationale: Moral courage involves taking action to do what is right, even when there might be negative consequences. The nurse who contacted a physician for further orders acted as a client advocate to seek help, even though she may have faced consequences such as lost time, decreased productivity, or criticism from the physician. Choices A, B, and D do not directly involve advocating for a client's needs or challenging a situation that goes against ethical standards. Feeling angry, seeking help for personal issues, or being frustrated with work processes do not necessarily demonstrate moral courage in the context of nursing practice.
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