NCLEX NCLEX-RN
NCLEX RN Exam Review Answers
1. Which of these clients is likely to receive sublingual morphine?
- A. A 75-year-old woman in a hospice program
- B. A 40-year-old man who just had throat surgery
- C. A 20-year-old woman with trigeminal neuralgia
- D. A 60-year-old man who has a painful incision
Correct answer: A 75-year-old woman in a hospice program
Rationale: The correct answer is a 75-year-old woman in a hospice program. Sublingual morphine is commonly used in hospice care because patients may have difficulty swallowing, and intravenous access can be uncomfortable and not ideal for palliative care. Choice B, a 40-year-old man who just had throat surgery, is less likely to receive sublingual morphine as he may be able to swallow, and other pain management options may be more suitable. Choice C, a 20-year-old woman with trigeminal neuralgia, would typically require specific medications targeting neuropathic pain rather than sublingual morphine. Choice D, a 60-year-old man with a painful incision, may benefit from localized pain relief or other systemic pain management options, but sublingual morphine is not usually the first choice for this type of pain.
2. What kind of preventive measures is MOST likely to be used to prevent Mary Eden from falling due to her muscular frailty?
- A. Physical therapy for muscle strengthening exercises
- B. Physical therapy for range of motion exercises
- C. Occupational therapy to help her with confusion
- D. Medications to help her sleep more
Correct answer: Physical therapy for muscle strengthening exercises
Rationale: Mary Eden, due to her muscular frailty, is at risk of falling. The most effective preventive measure in this case would be physical therapy focusing on muscle strengthening exercises. Strengthening exercises can help improve her muscle tone and stability, reducing the risk of falls. While range of motion exercises may be beneficial, they may not directly address her muscular frailty and stability concerns as effectively as muscle strengthening exercises. Occupational therapy aims to help individuals with activities of daily living and functional tasks, not confusion. Medications to induce more sleep can actually increase the risk of falls due to potential side effects like dizziness or disorientation, rather than preventing falls.
3. During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?
- A. Formulate a nursing diagnosis of impaired gas exchange
- B. Record in the medical record the distance a client ambulates in the hall
- C. Write individualized nursing orders in the care plan
- D. Compare client responses to the desired outcomes for pain relief
Correct answer: Record in the medical record the distance a client ambulates in the hall
Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.
4. During a class on religion and spirituality, the nurse is asked to define spirituality. Which statement by the nurse best describes spirituality?
- A. “Is a personal search to discover a supreme being.”
- B. “Is an organized system of beliefs concerning the cause, nature, and purpose of the universe.”
- C. “Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife.”
- D. “Focuses on a connection with something bigger than oneself and a belief in transcendence.”
Correct answer: “Focuses on a connection with something bigger than oneself and a belief in transcendence.”
Rationale: Spirituality is a broad term that focuses on a connection with something greater than oneself and a belief in transcendence. It is a personal journey that arises from unique life experiences and the individual's quest to find purpose and meaning in life. The correct answer emphasizes the essence of spirituality, which involves seeking a connection with a higher power and believing in transcendence. Choices A, B, and C, on the other hand, define aspects of religion rather than spirituality. Choice A refers to a personal search for a supreme being, which is more aligned with religious beliefs. Choice B describes an organized system of beliefs about the universe, typically associated with religion. Choice C pertains to beliefs about existence after death, such as reincarnation or the afterlife, which are often religious concepts. Therefore, the best description of spirituality is focusing on a connection with something beyond oneself and a belief in transcendence.
5. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening
- B. Perform tests for sexually transmitted diseases
- C. Discuss her high risk for cervical cancer
- D. Refer the client to a family planning clinic
Correct answer: Counsel the woman to consent to HIV screening
Rationale: Counsel the woman to consent to HIV screening. The client's behavior places her at high risk for HIV. Testing is the first step in identifying and managing the risk of HIV infection. Early detection allows for timely interventions and better outcomes. While performing tests for sexually transmitted diseases (choice B) is important, addressing the immediate and potentially life-threatening risk of HIV takes precedence. Discussing the risk for cervical cancer (choice C) is not the priority at this time as HIV screening is more urgent. Referring the client to a family planning clinic (choice D) is not the immediate priority given the client's current high-risk behavior and the need to address the immediate threat of HIV infection.
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