NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. When providing mouth care to a patient in a coma, what should you do to provide good and safe mouth care?
- A. keep the head of the bed up to prevent aspiration
- B. brush the teeth and rinse the mouth with a cup of water
- C. use a special foam swab to brush only the tongue
- D. use a special foam swab to brush the tongue and teeth
Correct answer: D
Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice C) or using a foam swab only on the tongue (choice B) may not provide the comprehensive mouth care necessary for patients in a coma.
2. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo?
- A. Trying prayer before seeking medical help
- B. Believing that illness is a punishment of sin
- C. Refusing to accept blood products as part of treatment
- D. Stating that a child's birth defect is the result of the parents' sins
Correct answer: C
Rationale: The concept of a cultural taboo involves practices that are forbidden or avoided within a particular culture. Refusing to accept blood products as part of treatment is a clear example of a cultural taboo, as some cultures or religions prohibit the use of blood products for medical purposes. This practice is deeply rooted in cultural beliefs and traditions. The other choices provided do not directly relate to cultural taboos. Trying prayer before seeking medical help, believing illness is a punishment of sin, and stating that a child's birth defect is the result of parents' sins are beliefs or actions based on religious or personal beliefs, but they do not specifically represent cultural taboos.
3. Which acronym would BEST describe the procedure for assessing a patient that appears unconscious?
- A. WBC
- B. QRS
- C. XYZ
- D. ABC
Correct answer: D
Rationale: The correct answer is D, 'ABC.' The ABC method stands for Airway, Breathing, Circulation. When encountering an unconscious patient, it is crucial to first ensure their Airway is clear by performing the 'head tilt, chin lift' maneuver. Next, assess Breathing by observing for chest rise and fall, listening for breath sounds, and feeling for airflow. Finally, check for Circulation by assessing for a pulse. Choices A, B, and C ('WBC,' 'QRS,' 'XYZ') are incorrect as they do not represent the standard approach to assessing an unconscious patient.
4. During the general survey, what action is a component of the assessment?
- A. Observing the patient's body stature and nutritional status
- B. Interpreting the subjective information reported by the patient
- C. Measuring the patient's temperature, pulse, respirations, and blood pressure
- D. Observing specific body systems during the physical assessment
Correct answer: A
Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.
5. A client is diagnosed with ariboflavinosis. Which of the following foods should the nurse serve this client?
- A. Citrus fruits
- B. Milk
- C. Fish
- D. Potatoes
Correct answer: B
Rationale: Ariboflavinosis is a vitamin B-2 deficiency. Symptoms may include cracks around the mouth, inflammation of the tongue, or light sensitivity. Foods rich in vitamin B-2, like milk, liver, green vegetables, or whole grains, are recommended. Citrus fruits (choice A) are good sources of vitamin C, not B-2. Fish (choice C) is a source of protein and omega-3 fatty acids but not a significant source of vitamin B-2. Potatoes (choice D) are a source of carbohydrates but do not provide high levels of vitamin B-2.
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