NCLEX 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: The Immunological Theory of Aging
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 client is admitted to a nursing unit with a remittent fever. Which statement best describes this pattern of fever?
- A. A fever that spikes and then lowers without returning to normal
- B. A fever that lasts 2 days followed by normal temperature for 2 days, followed by fever again
- C. A fever that lasts 2 days followed by normal temperature for 12 hours, followed by fever again
- D. A persistent fever that has lasted over 24 hours
Correct answer: A fever that spikes and then lowers without returning to normal
Rationale: A remittent fever is characterized by temperature fluctuations where the fever spikes and then lowers but does not return to normal temperature. Option A best describes this pattern of fever. Option B describes a pattern of fever known as a biphasic fever, where the fever alternates between days of fever and normal temperature. Option C describes a pattern of fever that is more indicative of an intermittent fever, where the fever lasts for a specific duration followed by an interval of normal temperature. Option D does not accurately describe a remittent fever, as it suggests a persistent fever that has lasted over 24 hours, which is not specific to the remittent pattern.
3. Jack is a 2-month-old with a diagnosis of spinal muscular atrophy (SMA) type I. He has been admitted to the hospital for progressive respiratory difficulty. His parents have been informed that if he is not placed on ventilatory support, he will continue to decompensate and die of respiratory failure. Jack's physician discusses the poor prognosis of Jack's condition, and tells the parents that he will not be able to be removed from ventilatory support once it is initiated, due to his progressive neurological disease. After much discussion, the parents have decided to decline ventilatory support, agree to a do not resuscitate (DNR) order, and request hospice care for Jack. Another parent heard them discussing Jack's situation in the waiting room and says she could never do that to her baby. What is the most appropriate response to this parent?
- A. You never know what you'll do until you're in that situation.
- B. I can't discuss another patient's situation.
- C. They have been through too much already.
- D. You can contact administration with your concerns.
Correct answer: I can't discuss another patient's situation.
Rationale: In healthcare settings, privacy regulations prevent professionals from discussing patient situations with individuals not involved in that patient's care. Maintaining patient confidentiality is crucial to protect sensitive information. In this scenario, sharing details about Jack's situation with the parent who overheard the conversation would breach confidentiality. It is important to handle such situations delicately, especially in emotional environments like intensive care unit waiting rooms. While empathy and support are essential, it is equally crucial to respect patient privacy and confidentiality. Therefore, responding with 'I can't discuss another patient's situation' is the most appropriate and professional response in this context.
4. A 20-year-old young adult has been recently admitted to the hospital. According to Erikson, which of the following stages is the adult in?
- A. Trust vs. mistrust
- B. Initiative vs. guilt
- C. Autonomy vs. shame
- D. Intimacy vs. isolation
Correct answer: Intimacy vs. isolation
Rationale: The young adult, at 20 years old, is in the stage of Intimacy vs. Isolation according to Erikson's psychosocial theory. This stage typically occurs during young adulthood, between the ages of approximately 19 and 40. The primary conflict in this stage revolves around the development of intimate, loving relationships with others. This stage focuses on establishing close bonds and connections with others, seeking emotional closeness and commitment. Choices A, B, and C are incorrect. Trust vs. mistrust is the stage that occurs in infancy, Initiative vs. guilt is in early childhood, and Autonomy vs. shame is in toddlerhood. These stages each represent different developmental challenges and conflicts that individuals face at various points in their lives.
5. A nurse is required to float to another unit within the hospital where he is asked to care for a client on a ventilator. The nurse is uncomfortable with this assignment, as he has not had a ventilated client since nursing school. What is the nurse's most appropriate response?
- A. Explain to the nursing supervisor the level of discomfort and ask for a different assignment
- B. State that the client's needs are outside the nurse's scope of practice and request a different assignment
- C. Accept the assignment, asking for help when necessary
- D. Request to return to the home unit and send another nurse who can perform the job
Correct answer: Explain to the nursing supervisor the level of discomfort and ask for a different assignment
Rationale: When floating to another unit and asked to take an assignment that falls outside a nurse's comfort zone, the nurse should notify the area supervisor of the level of discomfort and request a different assignment. Caring for ventilated clients typically falls within the scope of nursing practice; however, discomfort with the situation may not necessarily be overcome by accepting the assignment. Alternatively, the effects could be harmful to the client if the nurse is unfamiliar with this type of care. Requesting a different assignment is the most appropriate response in this situation, ensuring patient safety and the nurse's comfort level. Stating that the client's needs are outside the nurse's scope of practice (Choice B) may not be accurate, as caring for ventilated clients usually falls within the scope of nursing practice. Accepting the assignment (Choice C) without addressing the discomfort may compromise patient safety. Requesting to return to the home unit (Choice D) does not address the immediate need of caring for the ventilated client and may delay appropriate care.
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