NCLEX-RN
NCLEX RN Predictor Exam
1. Which of the following activities would the nurse perform during the diagnosing phase of the nursing process? Select all that apply.
- A. Collect and organize client information
- B. Analyze data
- C. Identify problems, risks, and client strengths
- D. Develop nursing diagnoses
Correct answer: B: Analyze data
Rationale: During the diagnosing phase of the nursing process, the nurse analyzes the collected data to identify problems, risks, and client strengths, which then leads to developing nursing diagnoses. Collecting and organizing client information is part of the assessment phase, where data is gathered. Developing nursing diagnoses comes after data analysis in the diagnosing phase. Goal setting is a component of the planning phase, which follows the diagnosing phase.
2. Which of the following tests would MOST LIKELY be performed on a patient who is being monitored for coagulation therapy?
- A. PT/INR
- B. CBC
- C. PTT
- D. WBC
Correct answer: A: PT/INR
Rationale: The correct answer is A: PT/INR. Prothrombin times (PT/INR) are commonly used to monitor patients on Coumadin (warfarin) therapy, an anticoagulant that slows the blood's ability to clot. Monitoring PT/INR levels helps ensure the patient is receiving the appropriate dosage of Coumadin. Choice B, CBC (Complete Blood Count), is a general test that provides information on red blood cells, white blood cells, and platelets but is not specific to monitoring coagulation therapy. Choice C, PTT (Partial Thromboplastin Time), is another coagulation test but is not as commonly used for monitoring Coumadin therapy. Choice D, WBC (White Blood Cell count), is unrelated to monitoring coagulation therapy and is used to assess immune system function.
3. During a client interview, which of the following leading questions should the nurse avoid asking?
- A. What medication do you take at home?
- B. You are really excited about the plastic surgery, aren't you?
- C. Were you aware I've had this same type of surgery?
- D. What would you like to talk about?
Correct answer: You are really excited about the plastic surgery, aren't you?
Rationale: The nurse should avoid asking leading questions during a client interview as they can influence the client's response. Option B is a leading question as it suggests an expected response from the client, potentially biasing the information provided. This can lead to inaccurate data collection and subsequent errors in diagnostic reasoning. Choices A, C, and D are open-ended questions that encourage the client to provide unbiased information and allow for a more comprehensive assessment.
4. During a general survey of a patient, which finding is considered normal?
- A. Body mass index (BMI) of 20.
- B. When standing, the patient’s base is narrow.
- C. The patient appears older than their stated age.
- D. Arm span (fingertip to fingertip) is greater than the height.
Correct answer: Body mass index (BMI) of 20.
Rationale: A body mass index (BMI) of 20 is considered normal as the range for a normal BMI is between 19-24. When standing, a patient's base should be wide for stability and proper weight distribution. An older appearance than the stated age may indicate a history of chronic illness or chronic alcoholism. In a general survey, the patient's arm span (fingertip to fingertip) should approximately equal the patient's height. An arm span greater than the height may suggest Marfan syndrome. Therefore, the correct choice is a normal BMI of 20, which falls within the healthy range. Choices B, C, and D all describe abnormal findings that may indicate underlying health conditions or syndromes.
5. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?
- A. Client will be able to turn self by day 3
- B. Skin will remain intact and without redness during hospital stay
- C. Client will state pain relieved within 30 minutes after medication
- D. Pressure will be prevented by repositioning client every 2 hours
Correct answer: Skin will remain intact and without redness during hospital stay
Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.
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