NCLEX-RN
NCLEX RN Exam Prep
1. You are ready to wash your patient's face. You would start by washing what area of the face?
- A. The forehead
- B. The eyes
- C. The ears
- D. The cheeks
Correct answer: B
Rationale: When washing a patient's face, it is essential to start by cleaning the eyes. The eye area is considered the priority because moving from an area that can potentially be infected to areas of the face and body that are least able to become infected with a washcloth helps prevent the spread of germs. Washing the forehead, ears, or cheeks before the eyes may risk transferring bacteria to a more sensitive area like the eyes, which could lead to infections or other complications. Therefore, starting with the eyes ensures proper hygiene and reduces the risk of introducing harmful microorganisms to the patient's face.
2. Which of the following lists the recommended sequence for removing soiled personal protective equipment when preparing to leave a patient's room?
- A. Gown, goggles, mask, gloves, and exit the room.
- B. Gloves, wash hands, remove gown, mask, and goggles.
- C. Gloves, goggles, gown, mask, and wash hands.
- D. Gloves, goggles, gown, mask, and wash hands.
Correct answer: D
Rationale: The correct sequence for removing soiled personal protective equipment is crucial to prevent contamination. Gloves should always be removed first as they are most likely to be contaminated. Following the removal of gloves, goggles, gown, mask, and finally washing hands is recommended. Choice A is incorrect as gloves should be removed first. Choice B is incorrect as the sequence is not in the recommended order. Choice D is incorrect as gloves should be removed before goggles.
3. 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: D
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.
4. A client is undergoing range of motion exercises, and the nurse moves the leg in a pattern of circumduction. Which movement is the nurse performing?
- A. Bending the leg at the knee
- B. Turning the foot inward and outward
- C. Moving the leg in a circle
- D. Moving the leg forward and up
Correct answer: C
Rationale: Circumduction involves moving a limb in a circular pattern. In this scenario, the nurse is performing circumduction by moving the leg in a circular motion, engaging the muscles of the gluteus maximus and gluteus medius. Choice A, 'Bending the leg at the knee,' is incorrect as it describes flexion and extension movements. Choice B, 'Turning the foot inward and outward,' refers to inversion and eversion movements of the foot, not circumduction. Choice D, 'Moving the leg forward and up,' describes flexion and abduction movements, not circumduction.
5. A patient's nursing diagnosis is Insomnia. The desired outcome is: 'Patient will sleep for a minimum of 5 hours nightly by October 31.' On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented?
- A. Consistently demonstrated
- B. Often demonstrated
- C. Sometimes demonstrated
- D. Never demonstrated
Correct answer: D
Rationale: The correct answer is 'Never demonstrated.' Despite the patient sleeping a total of 6 hours daily, it is not achieved in one uninterrupted session at night as per the desired outcome. The patient's habit of taking a 2-hour afternoon nap also affects the evaluation. Therefore, the outcome should be evaluated as 'Never demonstrated.' Choice A, 'Consistently demonstrated,' is incorrect because the desired outcome of sleeping for a minimum of 5 hours nightly in one session is not met. Choice B, 'Often demonstrated,' is incorrect as the patient's sleep pattern does not consistently align with the desired outcome. Choice C, 'Sometimes demonstrated,' is also incorrect as the patient's sleep pattern does not meet the specific criteria set in the desired outcome.
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