NCLEX-RN
NCLEX RN Exam Prep
1. A client's intake and output are being calculated by a nurse. During the last shift, the client consumed � cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client also urinated 250 cc and had 2 bowel movements. What is this client's intake and output for this shift?
- A. 420 cc intake, 250 cc output
- B. 300 cc intake, 250 cc output
- C. 550 cc intake, 550 cc output
- D. 300 cc intake, 550 cc output
Correct answer: A
Rationale: The correct answer is 420 cc intake and 250 cc output for this shift. To calculate the intake, � cup of gelatin (approximately 120 cc) and 300 cc of water should be added together, resulting in 420 cc. Food intake like the chicken breast and green beans is not converted to cc's but may be documented for hospital protocol. Output includes urine (250 cc in this case) and other forms like vomit, diarrhea, or gastric suction. Bowel movements are not converted to cc's, but the nurse may need to document the number of stools passed. Choices B, C, and D are incorrect because they do not accurately reflect the intake and output calculations based on the information provided.
2. Which of the following signs or symptoms indicates a possible nutritional deficiency?
- A. Subcutaneous fat at the waist and abdomen
- B. Presence of papillae on the surface of the tongue
- C. Straight arms and legs
- D. Pale conjunctiva
Correct answer: D
Rationale: A client with poor nutritional intake may have pale mucous membranes surrounding the eye, or the conjunctiva. This area should normally be pink, indicating good circulation and a lack of irritation or dryness. Improper nutrition can manifest as numerous signs in the body, including bowed legs, pale mucous membranes, a smooth or beefy tongue, and poor muscle tone. Subcutaneous fat at the waist and abdomen is not a sign of nutritional deficiency but rather of excess fat deposition. The presence of papillae on the surface of the tongue is normal and not indicative of a nutritional deficiency. Straight arms and legs are also typical anatomical features and not specifically related to nutritional deficiencies.
3. Improper placement of the hands under the rib cage when performing the Heimlich maneuver could result in:
- A. damage to the manubrium of the sternum.
- B. damage to the xiphoid process.
- C. damage to the coccyx.
- D. None of the above is possible, even with improper hand placement.
Correct answer: B
Rationale: The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum. Placing the hands improperly during the Heimlich maneuver too close to this process can result in it breaking off and potentially causing damage to internal organs. Choices A and C are incorrect because the manubrium of the sternum and the coccyx are not in the area where the hands would typically be placed during the Heimlich maneuver.
4. What is the flap of tissue that covers the trachea upon swallowing called?
- A. Epidermis
- B. Endocardium
- C. Epiglottis
- D. Epistaxis
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.
5. Match the abbreviation with the correct definition:
- A. bid: twice a day
- B. tid: three times a day
- C. ac: before meals
- D. pc: after meals
Correct answer: C
Rationale: The abbreviation 'ac' stands for 'ante cibum,' which means 'before meals.' 'Bid' means twice a day. 'Tid' means three times a day, and 'pc' means after meals. When interpreting medical abbreviations, it is crucial to understand their precise meanings to ensure accurate communication and patient care.
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