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. When checking for proper blood pressure cuff size, which guideline is correct?
- A. The standard cuff size is appropriate for all sizes.
- B. The length of the rubber bladder should equal 80% of the arm circumference.
- C. The width of the rubber bladder should equal 80% of the arm circumference.
- D. The width of the rubber bladder should equal 40% of the arm circumference.
Correct answer: D
Rationale: When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect. Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.
3. Which of the following is NOT an acceptable abbreviation?
- A. D/C
- B. tid
- C. bid
- D. qid
Correct answer: A
Rationale: The correct answer is A: D/C. D/C is not an acceptable abbreviation as it can be easily confused with both 'discharge' and 'discontinue.' The abbreviations 'tid' (three times a day), 'bid' (twice a day), and 'qid' (four times a day) are commonly used in medical contexts to indicate dosing frequencies and are widely accepted in healthcare settings.
4. Where is the pulse point located on the top of the foot?
- A. the dorsalis pedis
- B. This is the pulse point checked in patients with peripheral vascular problems.
- C. This pulse point may be absent in some patients due to a congenital anomaly.
- D. All of the above.
Correct answer: D
Rationale: The pulse point located on the top of the foot is known as the dorsalis pedis pulse point. It is situated on the arch of the foot, slightly lateral to the midline. This pulse point is commonly examined in patients with peripheral vascular problems to assess blood flow adequacy. Additionally, some individuals may not have this pulse point due to a congenital anomaly. Therefore, all the given statements are correct in relation to the dorsalis pedis pulse point, making 'All of the above' the correct answer. Choices A, B, and C are all individually valid characteristics of the dorsalis pedis pulse point, hence selecting 'All of the above' as the correct answer is appropriate.
5. During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which one of these statements by the nurse is most appropriate?
- A. "Your atrial dysrhythmias are under control."?
- B. "You have pitting edema and mild varicosities."?
- C. "Your pulse is 80 beats per minute, which is within the normal range."?
- D. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs in your lungs."?
Correct answer: C
Rationale: During an examination, providing brief educational information to the patient can enhance rapport, as long as the patient can comprehend the terminology. The most appropriate statement from the nurse is "Your pulse is 80 beats per minute, which is within the normal range." This statement conveys a vital sign in a way that is likely understandable to the patient. Choices A, B, and D use terminology that may be unfamiliar or confusing to the patient. Option A mentions 'atrial dysrhythmias,' which might not be clear to the patient. Option B involves terms like 'pitting edema' and 'varicosities,' which could be unfamiliar to the patient. Option D references 'crackles,' 'wheezes,' and 'rubs,' which might not be easily understood by the patient.
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