NCLEX-RN
NCLEX RN Exam Review Answers
1. As a nursing supervisor in a long-term care facility, you prioritize strict infection control prevention measures due to the understanding that the normal aging process weakens the body's defenses. Which theory of aging supports the necessity of strict infection control prevention measures?
- A. The Programmed Longevity Theory
- B. The Immunological Theory of Aging
- C. The Endocrine Theory
- D. The Rate of Living Theory
Correct answer: B
Rationale: The theory of aging that aligns with the need for strict infection control prevention measures is the Immunological Theory of Aging. This theory posits that aging leads to a decline in the body's immune defenses and a reduced ability of antibodies to protect against infections. The other theories do not directly address the impact of aging on the immune system. The Programmed Longevity Theory focuses on genetic changes affecting aging, the Endocrine Theory emphasizes hormonal changes, and the Rate of Living Theory relates longevity to the rate of oxygen metabolism.
2. A nurse is performing an end-of-shift count of narcotics kept in the locked cabinet. The narcotic log states there should be 26 oxycodone pills left, but there are only 24 in the drawer. What is the first action of the nurse?
- A. Perform the count again
- B. Contact the pharmacy to determine if the narcotic log is incorrect
- C. Check with the last nurse to sign out narcotics from the system
- D. Notify the house supervisor that narcotic medications are missing
Correct answer: A
Rationale: The first action the nurse should take in this situation is to perform the count again. This step is crucial to ensure there was no miscount during the initial check. By verifying the count, the nurse can confirm if there is indeed a discrepancy in the number of oxycodone pills. Contacting the pharmacy, checking with the last nurse, or notifying the house supervisor should only be considered after ensuring the count is accurate. It's important to rule out any human error before escalating the issue to others.
3. Which of the following tasks may be delegated to unlicensed assistive personnel?
- A. Cleansing a wound with peroxide
- B. Irrigating a colostomy
- C. Assisting with performing incentive spirometry
- D. Removing a saline-lock IV
Correct answer: C
Rationale: Certain tasks can be safely delegated to unlicensed assistive personnel to assist nurses in their workload. Tasks that involve routine activities like incentive spirometry can be delegated. Unlicensed assistive personnel can assist clients with incentive spirometry, helping in promoting lung expansion and preventing respiratory complications. Cleansing a wound with peroxide (Choice A) and irrigating a colostomy (Choice B) involve more complex procedures that should be performed by licensed healthcare providers due to the risk of infection and potential complications. Removing a saline-lock IV (Choice D) requires specialized training and should only be performed by licensed personnel to prevent complications and ensure patient safety. The nurse remains responsible for delegating tasks appropriately and overseeing the care provided by unlicensed assistive personnel.
4. One of the complications of complete bed rest and immobility is which of the following?
- A. Plantar flexion
- B. Dorsiflexion
- C. Extension contractures
- D. Adduction contractures
Correct answer: A
Rationale: Plantar flexion, or foot drop, is a common complication of complete bed rest and immobility. This condition occurs due to the weakening of muscles that lift the foot, leading to the foot dragging or being unable to clear the ground during walking. Dorsiflexion refers to moving the foot upwards, which is not a typical complication of immobility. Extension contractures involve the inability to fully extend a joint, while adduction contractures refer to the inability to move a limb away from the body. These types of contractures can also occur with immobility, but they are not specifically associated with foot drop.
5. Which of the following white blood cells is the smallest and can be involved in humoral immunity?
- A. Lymphocyte
- B. Monocyte
- C. Basophil
- D. Erythrocyte
Correct answer: A
Rationale: The correct answer is 'Lymphocyte.' Lymphocytes are the smallest type of white blood cells and play a crucial role in humoral immunity by producing antibodies. Monocytes are actually the largest white blood cells and are involved in phagocytosis rather than humoral immunity. Basophils are a type of granulocyte involved in allergic reactions, and erythrocytes are red blood cells responsible for oxygen transport, not part of the immune system.
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