NCLEX-RN
NCLEX RN Exam Prep
1. A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct answer: C
Rationale: The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams. Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.
2. The healthcare provider is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?
- A. Usually yields little information
- B. Takes time and reveals a surprising amount of information
- C. May be somewhat uncomfortable for the expert practitioner
- D. Requires a thorough examination of the patient's body before proceeding with palpation
Correct answer: B
Rationale: During the inspection phase of a physical assessment, it is essential to take time as it can reveal a significant amount of information. Initially, it may feel uncomfortable for the examiner to focus solely on observing the patient without immediate action. Rushing through inspection is not recommended as it can lead to missing important cues. Train yourself to be thorough during inspection by observing carefully and taking the time needed to gather essential data. Choices A, C, and D are incorrect because inspection typically provides valuable information, may feel uncomfortable at first but is necessary for a comprehensive assessment, and does not involve a quick glance but requires a focused and detailed observation.
3. Where is the pulse point located on the top of the foot?
- A. the dorsalis pedis
- B. This is the pulse point checked in patients with peripheral vascular problems.
- C. This pulse point may be absent in some patients due to a congenital anomaly.
- D. All of the above.
Correct answer: D
Rationale: The pulse point located on the top of the foot is known as the dorsalis pedis pulse point. It is situated on the arch of the foot, slightly lateral to the midline. This pulse point is commonly examined in patients with peripheral vascular problems to assess blood flow adequacy. Additionally, some individuals may not have this pulse point due to a congenital anomaly. Therefore, all the given statements are correct in relation to the dorsalis pedis pulse point, making 'All of the above' the correct answer. Choices A, B, and C are all individually valid characteristics of the dorsalis pedis pulse point, hence selecting 'All of the above' as the correct answer is appropriate.
4. Which statement best describes evidence-based practice?
- A. Reading and analyzing research reports to determine their implementation in nursing practice
- B. Collecting data to evaluate the efficiency of nursing practice in delivering quality care
- C. Monitoring unit practices to ensure adherence to Joint Commission standards
- D. Using the most effective, current, and applicable information to guide nursing care for the best outcomes
Correct answer: D
Rationale: Evidence-based practice involves utilizing the most effective, current, and relevant information to inform nursing care decisions for optimal client outcomes. While research reports and data collection are important components of evidence-based practice, the essence lies in integrating all available information to determine the best course of action. Monitoring compliance with standards, as described in choices A and C, is essential for quality assurance but does not capture the comprehensive nature of evidence-based practice.
5. A healthcare professional is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?
- A. Cephalic
- B. Median cubital
- C. Basilic
- D. All of the above
Correct answer: D
Rationale: The correct answer is 'All of the above.' All three of these veins - the cephalic, median cubital, and basilic veins - are located in the antecubital space, which is the area in front of the elbow on the arm. The cephalic vein runs along the outer side of the arm, the basilic vein runs along the inner side of the arm, and the median cubital vein is a connecting vein between the cephalic and basilic veins. Therefore, all three veins can be accessed when drawing blood from the antecubital space. Choices A, B, and C are incorrect because each of these veins individually can be found in the antecubital space.
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