NCLEX-RN
NCLEX RN Exam Prep
1. You are working the 4 pm to 12 midnight evening shift. You are taking care of a group of patients. The supervising RN identifies 5 patients who get a medication at 'HS'. When will you give this medication?
- A. After the dinner meal
- B. Whenever requested
- C. At the patient's bedtime
- D. Before the end of the shift
Correct answer: C
Rationale: The correct answer is to give the medication at the patient's bedtime. 'HS' is a medical abbreviation that stands for 'hora somni,' which translates to 'at bedtime' or 'at the hours of sleep.' This timing ensures that the medication is administered appropriately to align with the patient's sleep schedule and maximize its effectiveness. Choices A, B, and D are incorrect because giving the medication after dinner, whenever requested, or before the end of the shift may not coincide with the intended purpose of the medication, potentially affecting its efficacy and patient outcomes.
2. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
- A. Listen to a patient's lung sounds for wheezes or rhonchi.
- B. Label specimens obtained during percutaneous lung biopsy.
- C. Instruct a patient about how to use home spirometry testing.
- D. Measure induration at the site of a patient's intradermal skin test.
Correct answer: B
Rationale: Labeling specimens obtained during a percutaneous lung biopsy is a task that can be appropriately delegated to unlicensed assistive personnel (UAP) as it does not require nursing judgment. UAP can perform this task safely under the supervision of a nurse. Listening to a patient's lung sounds for wheezes or rhonchi, instructing a patient about how to use home spirometry testing, and measuring induration at the site of a patient's intradermal skin test all require nursing judgment and interpretation of findings. These tasks should be performed by licensed nursing personnel to ensure accurate assessment and appropriate intervention.
3. After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods?
- A. Return demonstration
- B. Explanation
- C. Achievement of 90 on written test
- D. Have the client explain the procedure to the family
Correct answer: A
Rationale: After teaching the client on crutch walking technique, assessing the client's understanding is crucial. The most effective method to evaluate the client's comprehension of a hands-on skill like crutch walking technique is through a return demonstration. This allows the nurse to observe the client performing the technique, ensuring they have grasped the instructions correctly and can execute the skill safely. While providing an explanation can help clarify doubts, it may not confirm the client's ability to perform the skill. Achieving a high score on a written test assesses cognitive understanding but not necessarily the practical application of the skill. Having the client explain the procedure to the family does not directly assess their ability to perform the skill themselves; it tests their ability to communicate the information to others.
4. When a patient refuses to believe a terminal diagnosis, they are exhibiting:
- A. Regression
- B. Mourning
- C. Denial
- D. Rationalization
Correct answer: C
Rationale: Denial is a defense mechanism where a patient rejects a reality that is too painful or difficult to accept. In the context of a terminal diagnosis, the patient may refuse to believe it in order to avoid facing the harsh truth. Regression (choice A) involves reverting to earlier, more childlike behaviors and is not applicable in this scenario. Mourning (choice B) is the process of grieving a loss, which typically occurs after acceptance of the diagnosis. Rationalization (choice D) is creating logical explanations to justify unacceptable behaviors, which is not the case when a patient denies a terminal diagnosis.
5. When assessing a patient's pulse, which of the following characteristics would the nurse also notice?
- A. Force
- B. Pallor
- C. Capillary refill time
- D. Timing in the cardiac cycle
Correct answer: A
Rationale: When assessing a patient's pulse, the nurse should observe characteristics such as rate, rhythm, and force. Force refers to the strength or amplitude of the pulse, which provides important information about cardiac output. Pallor is the paleness of the skin and is not directly related to pulse assessment. Capillary refill time is used to assess peripheral perfusion and is not specifically part of pulse assessment. Timing in the cardiac cycle is a broader concept and not a characteristic directly assessed during a pulse examination. Therefore, choice A, 'Force,' is the correct answer as it aligns with the standard parameters evaluated during pulse assessment.
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