NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. What message is a patient sending when displaying the following body language: Slumped shoulders, grimace, and stiff joints?
- A. Anger
- B. Aloofness
- C. Empathy
- D. Depression
Correct answer: A
Rationale: Body language is a powerful form of non-verbal communication that can convey various emotions. In this scenario, the patient's slumped shoulders, grimace, and stiff joints suggest a negative emotional state. Anger is the correct answer because grimacing and tense posture are commonly associated with anger. Choice B, 'Aloofness,' is incorrect as aloofness is more related to disinterest or detachment, which is not indicated by the described body language. Choice C, 'Empathy,' is incorrect as the body language described does not align with expressing understanding or compassion towards others. Choice D, 'Depression,' is incorrect as while depression can also manifest through body language, the specific cues given in the scenario lean more towards anger than depression.
2. A physician asks you to place the patient with his dorsal side facing the exam table. Which of the following accurately describes how the patient is positioned?
- A. The patient is lying prone.
- B. The patient is lying supine.
- C. The patient is lying in the recovery position.
- D. The patient is lying on his stomach.
Correct answer: B
Rationale: When the physician asks for the patient to be placed with their dorsal side facing the exam table, it means the patient should be lying on their back. This position is known as the supine position, where the patient's back is on the table, facing up towards the ceiling. Choice A, 'The patient is lying prone,' is incorrect as the prone position is when the patient is lying face down. Choice C, 'The patient is lying in the recovery position,' is incorrect as the recovery position is a lateral position typically used in first aid. Choice D, 'The patient is lying on his stomach,' is incorrect as it describes the prone position, not the supine position as required in this scenario.
3. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?
- A. Respirations should be counted for 1 full minute.
- B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
- C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
- D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.
Correct answer: A
Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.
4. The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?
- A. The pulse is easier to palpate due to the rigidity of the blood vessels.
- B. An increased respiratory rate and a shallower inspiratory phase are expected findings.
- C. A widened pulse pressure occurs from changes in the systolic and diastolic blood pressures.
- D. Changes in the body's temperature regulatory mechanism decrease the older adult's likelihood of developing a fever.
Correct answer: B
Rationale: Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. As a result, the examiner may observe a shallower inspiratory phase and an increased respiratory rate in older adults. Contrary to common belief, the increased rigidity of arterial walls actually makes the pulse easier to palpate in aging adults. Pulse pressure is widened, not decreased, due to changes in systolic and diastolic blood pressures. Furthermore, changes in the body's temperature regulatory mechanism make older individuals less likely to develop a fever but more susceptible to hypothermia.
5. A urine pregnancy test:
- A. May be negative even if a blood pregnancy test is positive.
- B. Is positive only during the first trimester of pregnancy.
- C. Will be negative if the amount of LH isn't enough to meet or exceed the sensitivity of the testing device.
- D. All of the above.
Correct answer: A
Rationale: A urine pregnancy test detects HCG in a pregnant woman's urine. Blood levels of HCG are usually higher and register earlier than HCG levels in the urine. Choice A is correct because urine pregnancy tests may be negative even if a blood pregnancy test is positive due to the differences in HCG levels in blood and urine. Choice B is incorrect because a urine pregnancy test can be positive throughout pregnancy, not just in the first trimester. Choice C is incorrect because LH (luteinizing hormone) is not the hormone detected in a pregnancy test; it is HCG (human chorionic gonadotropin). Choice D is incorrect because not all the statements provided are true.
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