NCLEX-RN
NCLEX RN Exam Prep
1. You are taking care of 7 patients today. One of your residents wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care task is the lowest in terms of priority?
- A. The water
- B. Help to the bathroom
- C. The chest pain
- D. The crying person
Correct answer: D
Rationale: The lowest priority patient care task in this scenario is addressing the emotional need of the patient who is crying because his daughter did not visit him today. While emotional support is important, the other needs - providing water, assisting to the bathroom, and addressing chest pain - are physical needs that must take priority as they directly impact the patient's well-being and health. It is crucial to acknowledge and address emotional needs but in this situation, the physical needs of the patients should be addressed first.
2. When assessing the force or strength of a pulse, what would the nurse recall about the pulse?
- A. Is a reflection of the heart's stroke volume
- B. Typically recorded on a 0- to 3-point scale
- C. Demonstrates elasticity of the blood vessel wall
- D. Reflects the blood volume in the arteries during diastole
Correct answer: A
Rationale: When assessing the force or strength of a pulse, the nurse should recall that it is a reflection of the heart's stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta, causing arterial walls to flare and generate a pressure wave felt as the pulse in the periphery. The force of the pulse is typically recorded on a 0- to 3-point scale, not a 0- to 2-point scale. The force of the pulse does not demonstrate the elasticity of blood vessel walls or reflect the blood volume in the arteries during diastole. Therefore, choices B, C, and D are incorrect.
3. What term is used to describe the sexual response changes among middle-aged men?
- A. Menopause
- B. Climacteric
- C. Generativity
- D. Maturity
Correct answer: B
Rationale: The correct answer is 'Climacteric.' Climacteric specifically refers to the period in middle-aged men characterized by sexual response changes, such as delayed arousal. Menopause, choice A, is incorrect as it is specific to women and marks the cessation of menstrual periods. Generativity, choice C, is unrelated as it refers to the concern for guiding the next generation. Maturity, choice D, is too broad and generally refers to reaching the adult stage of development, not specifically addressing sexual response changes in middle-aged men.
4. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects this philosophy's view of "health"??
- A. A person is able to work and produce.
- B. A person is happy, stable, and feels good.
- C. All aspects of the person are in perfect balance.
- D. A person is able to care for others and function socially.
Correct answer: C
Rationale: In the yin/yang theory rooted in ancient Chinese philosophy, health is believed to exist when all aspects of a person are in perfect balance. This includes physical, mental, emotional, and spiritual well-being. Choice C accurately reflects this philosophy's view of health. Choices A, B, and D do not capture the essence of the yin/yang theory. Being able to work and produce, being happy and stable, or caring for others and functioning socially, while important, do not encompass the holistic balance emphasized in the yin/yang theory.
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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