NCLEX NCLEX-RN
NCLEX RN Exam Review Answers
1. You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?
- A. Use the old stock from a previous company
- B. Verify the cuff pressures every hour to ensure accuracy
- C. Notify the risk manager
- D. Form a peer workgroup to evaluate new products
Correct answer: Form a peer workgroup to evaluate new products
Rationale: Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments. Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.
2. A client diagnosed with sexual dysfunction states, 'Well, I guess my sex life is over.' Which response would the nurse use as a reply?
- A. 'I’m sorry to hear that.'
- B. 'Oh, you have a lot of good years left.'
- C. 'You are concerned about your sex life?'
- D. 'Have you asked your primary health care provider about that?'
Correct answer: 'You are concerned about your sex life?'
Rationale: The response 'You are concerned about your sex life?' explores the meaning of the statement and allows further expression of concern. It shows empathy and encourages the client to elaborate on their feelings. Choice A, 'I’m sorry to hear that,' does not prompt the client to share more about their concerns and may close off communication. Choice B, 'Oh, you have a lot of good years left,' lacks empathy and understanding of the client's emotions, diverting the focus from the client's feelings. Choice D, 'Have you asked your primary health care provider about that?' shifts the responsibility away from the nurse and may not address the client's emotional needs, potentially making them feel dismissed or embarrassed to seek help.
3. Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept differences in the way a pregnant woman is cared for in her current residence?
- A. Cultural desire
- B. Cultural awareness
- C. Cultural knowledge
- D. Cultural encounters
Correct answer: Cultural desire
Rationale: The correct answer is 'Cultural desire.' Cultural desire involves the nurse's motivation and commitment toward caring for individuals from diverse backgrounds. In this scenario, motivating the immigrant to accept differences in prenatal care reflects the nurse's genuine interest in providing culturally competent care. Cultural awareness involves self-examination of one's beliefs and biases. Cultural knowledge refers to understanding various cultural practices and beliefs. Cultural encounters focus on interactions across cultures to enhance communication and mutual understanding. Therefore, in this context, the nurse's actions align more closely with the concept of cultural desire.
4. The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?
- A. Consult with the pharmacist about the need to continue the medication.
- B. Administer the antihypertensive medication as prescribed preoperatively.
- C. Withhold the medication until the client is fully alert and vital signs are stable.
- D. Contact the health care provider to renew the prescription for the medication.
Correct answer: Contact the health care provider to renew the prescription for the medication.
Rationale: In this scenario, the nurse has noted that an antihypertensive medication prescribed preoperatively is missing from the postoperative prescriptions. It is essential to renew preoperative medications postoperatively. Therefore, the correct action for the nurse to take is to contact the health care provider to renew the prescription for the antihypertensive medication. Consulting with the pharmacist about the need to continue the medication is not appropriate in this situation as pharmacists do not prescribe or renew medications. Administering the antihypertensive medication as prescribed preoperatively without a current prescription poses a risk to the client's safety. Withholding the medication until the client is fully alert and vital signs are stable does not address the issue of the missing prescription and delays the client's necessary treatment.
5. For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?
- A. Anxiety
- B. Hostility
- C. Aggression
- D. Withdrawal
Correct answer: Anxiety
Rationale: When a client with obsessive-compulsive disorder is interrupted while performing a ritual, the most likely reaction is anxiety. The compulsive ritual serves as a coping mechanism to control anxiety, so any disruption to this ritual can heighten the individual's anxiety levels. Hostility is typically part of the disorder itself and not a direct reaction to the interruption of the ritual. Aggression may occur only if anxiety escalates to a panic level, leading to overt anger expression. Withdrawal is not a common behavioral pattern associated with obsessive-compulsive disorder and is not a typical reaction to ritual interruption.
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