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. How many cc are there in 25 ounces?
- A. 250
- B. 500
- C. 750
- D. 1000
Correct answer: C
Rationale: To convert ounces to cc, we know that there are 30 cc in 1 ounce. Therefore, to find out how many cc are in 25 ounces, we multiply 30 cc/ounce by 25 ounces which equals 750 cc. This makes choice C, 750, the correct answer. Choices A, B, and D are incorrect as they do not correctly convert ounces to cc.
3. A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This situation illustrates which concept?
- A. Integration
- B. Assimilation
- C. Biculturalism
- D. Heritage consistency
Correct answer: B
Rationale: Assimilation is a unidirectional, linear process moving from unacculturated to acculturated, in which a person develops a new cultural identity and becomes like members of the dominant culture. In this scenario, the woman has adapted to the new culture by learning the language, dressing like her peers, and expressing that her family in Europe would hardly recognize her. This aligns with the process of assimilation. Integration and biculturalism, on the other hand, involve bidirectional and bidimensional processes that induce reciprocal change in both cultures while maintaining aspects of the original culture in one's ethnic identity. Since there is no indication in the question that the woman has retained aspects of her original culture, integration and biculturalism are not the correct concepts. Heritage consistency refers to the degree to which one retains their original or traditional culture, which is not addressed in the scenario provided.
4. How does the procedure for taking a pulse rate on an infant differ from an adult?
- A. Pulse rates are taken on infants using a different method.
- B. The apical pulse method is used on infants.
- C. Pulse rates on infants are taken with a sphygmomanometer.
- D. Pulse rates on infants are taken apically in the third intercostal space.
Correct answer: B
Rationale: The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately. Choices A, C, and D are incorrect. Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method. Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates. Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.
5. Which of the following is an example of physical abuse?
- A. A slap to the person's hand
- B. Threatening the person
- C. Ignoring and isolating a person
- D. Leaving a patient soiled for hours
Correct answer: A
Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.
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