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. When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?
- A. Interpret that the patient is eager and interested in participating in the interview.
- B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
- C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
- D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Correct answer: D
Rationale: Assuming a tripod position"?leaning forward with arms braced on chair arms"?occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.
3. To which of the following do the CDC Standard precautions recommendations apply?
- A. Patients with diagnosed infections only
- B. Blood or body fluids with visible blood only
- C. All body fluids including sweat
- D. All patients receiving care in hospitals
Correct answer: D
Rationale: The correct answer is 'All patients receiving care in hospitals.' Standard precautions apply to all patients in healthcare settings, regardless of their infection status. These recommendations include all body fluids except sweat, non-intact skin, and mucous membranes. Choice A is incorrect as standard precautions are not limited to patients with diagnosed infections. Choice B is incorrect as standard precautions extend beyond blood or body fluids with visible blood. Choice C is incorrect as sweat is an exception to the body fluids covered under standard precautions.
4. A patient in a clinic has been diagnosed with hepatitis A. What is the most likely route of transmission?
- A. Sexual contact with an infected partner
- B. Contaminated food
- C. Blood transfusion
- D. Illegal drug use
Correct answer: B
Rationale: The correct answer is contaminated food. Hepatitis A is primarily transmitted through the fecal-oral route, often through the ingestion of contaminated food or water. It is caused by the Hepatitis A virus (HAV), which is a single-stranded, positive-sense RNA virus. Sexual contact with an infected partner is more commonly associated with hepatitis B and C. Blood transfusion is a potential route for hepatitis B and C transmission due to bloodborne pathogens. Illegal drug use, particularly involving shared needles, is a common route for hepatitis C transmission.
5. Which of the following is an example of a positive effect of exercise on a client?
- A. Decreased basal metabolic rate
- B. Decreased venous return
- C. Decreased work of breathing
- D. Decreased gastric motility
Correct answer: C
Rationale: The correct answer is 'Decreased work of breathing.' Exercise has numerous positive effects on clients, such as increasing metabolic rate, improving gastric motility, and enhancing venous return. When a client exercises regularly, their work of breathing decreases, meaning that everyday activities require less exertion. This is beneficial as it indicates improved cardiovascular and respiratory efficiency. Choices A, B, and D are incorrect because a decreased basal metabolic rate, decreased venous return, and decreased gastric motility are not typically considered positive effects of exercise. Instead, an increased basal metabolic rate, improved venous return, and optimal gastric motility are desired outcomes associated with physical activity.
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