NCLEX 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: Anger
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. When a nurse's hand comes in contact with a client's blood after providing wound care, what is the next action the nurse should take?
- A. Use an alcohol-based hand sanitizer to disinfect the hands
- B. Wash hands with soap and water using appropriate technique
- C. Notify the appropriate personnel about the exposure to client's blood
- D. Sample some of the client's blood to determine the presence of diseases
Correct answer: Wash hands with soap and water using appropriate technique
Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.
3. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?
- A. The skin on the arm appears mottled
- B. The cold pack has been in place for 10 minutes
- C. The client complains of feeling nauseated
- D. The capillary refill in the area distal to the arm is 2 seconds
Correct answer: The skin on the arm appears mottled
Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.
4. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?
- A. Cuff should be placed on the patient’s arm and inflated 30 mm Hg above the point at which the palpated pulse disappears.
- B. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading.
- C. Cuff should be inflated 30 mm Hg above the patient’s pulse rate.
- D. After confirming the patient’s previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.
Correct answer: Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears.
Rationale: When measuring blood pressure, it's important to account for the possibility of an auscultatory gap, which occurs in about 5% of individuals, particularly those with hypertension due to a noncompliant arterial system. To detect an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears. This ensures an accurate measurement of blood pressure by overcoming the potential gap in sounds. Choice A is correct as it follows this guideline. Choices B and C are incorrect because inflating the cuff to 200 mm Hg or above the patient's pulse rate does not address the specific issue of an auscultatory gap. Choice D is incorrect as it focuses on the patient's previous readings rather than the current measurement technique needed to detect an auscultatory gap.
5. One major difference between long term care and respite centers is the fact that long term care facilities:
- A. provide both physical and emotional care on an ongoing basis, while respite centers offer only temporary services.
- B. provide care for residents on a long-term basis, while respite centers offer only outpatient services.
- C. provide care for residents on a long-term basis, while respite centers offer only temporary services.
- D. There is no difference. Long-term care and respite care are the same.
Correct answer: provide care for residents on a long-term basis, while respite centers offer only temporary services.
Rationale: The major difference between long-term care and respite centers is that long-term care facilities provide both physical and emotional care on an ongoing, long-term basis. This continuous care is essential for residents who require extended assistance. In contrast, respite centers offer temporary services, providing similar care but for a short-term duration. These short-term services are designed to give family caregivers a break from their daily responsibilities. Choice A is incorrect because both long-term care and respite centers can offer both physical and emotional care, but the key distinction lies in the duration of care provided. Choice B is incorrect as respite centers do not typically offer outpatient services, and the focus is on temporary relief rather than long-term care. Choice D is incorrect as the question clearly highlights a major difference between long-term care and respite centers.
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