NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. A healthcare professional realizes after a patient has left the office that they forgot to document the patient's complaint of a sore throat. Which of the following choices would BEST correct the error?
- A. Pull out that page of the chart and rewrite it with the correct information.
- B. Put one line through the original Chief Complaint, write 'ERROR,' your initials, and today's date. Make the correction by rewriting the Chief Complaint with the correct information.
- C. Go to the next available line of the SOAP notes. Write the current date, then write 'Late Entry.' Place the date and time when the patient stated they had a sore throat. Sign and date the entry.
- D. All of the above are incorrect.
Correct answer: C
Rationale: When adding information to a patient's chart after the encounter, using the term 'Late Entry' is essential. This clearly indicates that the information was added after the fact and helps to maintain the accuracy and integrity of the medical record. Option A is incorrect because removing a page from the chart and rewriting it can lead to inaccuracies and is not a recommended practice for correcting errors. Option B suggests marking the original Chief Complaint as an error, which may not be clear to future readers of the chart and could lead to confusion. Option D is incorrect as it dismisses the correct approach outlined in Option C, which is the best way to handle the situation of missed documentation during a patient encounter.
2. The categories such as ethnicity, gender, and religion illustrate which concept?
- A. Family
- B. Cultures
- C. Spirituality
- D. Subcultures
Correct answer: D
Rationale: Within cultures, various groups of people share different beliefs, values, and attitudes due to factors such as ethnicity, religion, education, occupation, age, and gender. When these distinct groups coexist within a broader culture, they are referred to as subcultures. While ethnicity, gender, and religion are important components of individuals' identities, they do not represent the concepts of family, cultures, or spirituality. The correct answer is 'Subcultures' as these categories reflect differences within a larger cultural context, emphasizing the unique characteristics shared by members of subcultural groups.
3. What technique would the nurse use to accurately assess a rectal temperature in an adult?
- A. Use a lubricated blunt tip thermometer.
- B. Insert the thermometer 2 to 3 inches into the rectum.
- C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
- D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
Correct answer: A
Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.
4. Nursing care plans contain which of the following?
- A. nursing diagnoses
- B. medical diagnoses.
- C. MD orders.
- D. intake and output forms
Correct answer: A
Rationale: Nursing care plans are legal documents that contain nursing diagnoses, such as an "Alteration of respiratory function". They also contain patient goals and nursing interventions.
5. A client is undergoing range of motion exercises, and the nurse moves the leg in a pattern of circumduction. Which movement is the nurse performing?
- A. Bending the leg at the knee
- B. Turning the foot inward and outward
- C. Moving the leg in a circle
- D. Moving the leg forward and up
Correct answer: C
Rationale: Circumduction involves moving a limb in a circular pattern. In this scenario, the nurse is performing circumduction by moving the leg in a circular motion, engaging the muscles of the gluteus maximus and gluteus medius. Choice A, 'Bending the leg at the knee,' is incorrect as it describes flexion and extension movements. Choice B, 'Turning the foot inward and outward,' refers to inversion and eversion movements of the foot, not circumduction. Choice D, 'Moving the leg forward and up,' describes flexion and abduction movements, not circumduction.
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