NCLEX-RN
NCLEX RN Actual Exam Test Bank Questions
Question 1 of 5
When providing mouth care to a patient in a coma, what should you do to provide good and safe mouth care?
Correct Answer: D
Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice C) or using a foam swab only on the tongue (choice B) may not provide the comprehensive mouth care necessary for patients in a coma.
Question 2 of 5
A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
Correct Answer: B
Rationale: The priority nursing diagnosis in this scenario is 'Risk for suicide.' When a patient presents with major depression, significant weight loss, suicidal ideation, and lack of symptom improvement despite medication, the immediate concern is to address the risk of suicide. 'Risk for suicide' takes precedence as it involves a direct threat to the patient's life. 'Imbalanced nutrition: Less than body requirements' may be a concern but does not take priority over the risk of suicide. 'Chronic low self-esteem' and 'Hopelessness' are relevant issues in depression but are not as urgent as addressing the immediate risk of suicidal behavior.
Question 3 of 5
A patient suffering from hyperglycemia would be experiencing:
Correct Answer: B
Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.
Question 4 of 5
What is the flap of tissue that covers the trachea upon swallowing called?
Correct Answer: C
Rationale: The correct answer is C: Epiglottis. The epiglottis is a flap of tissue that covers the trachea when swallowing to prevent food or liquid from entering the airway. Choice A, Epidermis, is the outer layer of the skin and is not related to the trachea. Choice B, Endocardium, is the inner lining of the heart chambers and is also unrelated to the trachea. Choice D, Epistaxis, refers to a nosebleed and is not the correct term for the tissue covering the trachea.
Question 5 of 5
Where is the duodenum located in the digestive system?
Correct Answer: D
Rationale: The duodenum is the first part of the small intestine, located immediately after the stomach. It is where the majority of digestion takes place in the gut. The pancreas delivers digestive juices containing amylase and lipase, while the gall bladder delivers bile to aid in the digestion of fats. Choice A incorrectly states that the duodenum is the third section of the small intestine, which is inaccurate. Choice B incorrectly associates the duodenum with the gall bladder, which is not where the duodenum is located. Choice C incorrectly states that the duodenum is where the pancreas delivers digestive juices, which is partly correct but not the main function of the duodenum. Therefore, the correct answer is 'None of the above' as none of the choices accurately describe the location or functions of the duodenum.
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