NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?
- A. 142/92
- B. 118/72
- C. 120/80
- D. 138/88
Correct answer: A
Rationale: Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension. Choice A, 142/92, falls within this range, making it the correct answer. Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension. Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.
2. In a 68-year-old man, a gradual loss of hearing is known as _____________.
- A. presbycusis
- B. xerostomia
- C. myopia
- D. presbyopia
Correct answer: A
Rationale: The correct answer is 'presbycusis.' Presbycusis is the age-related gradual loss of hearing ability, commonly seen in the elderly population. Xerostomia refers to dry mouth, myopia is nearsightedness, and presbyopia is the age-related loss of the eye's ability to focus on close objects. Given Mr. Roberts' age and symptom of gradual hearing loss, presbycusis is the most likely diagnosis. Xerostomia, myopia, and presbyopia do not match the sensory change described in the question, making them incorrect choices.
3. The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or healthcare providers, the nurse emphasizes interventions that do which of the following? (Berman & Snyder, 2012, p. 713)
- A. Eliminate the reservoir
- B. Block the portal of exit from the reservoir
- C. Block the portal of entry into the host
- D. Decrease the susceptibility of the host
Correct answer: B
Rationale: To prevent the spread of infection from a chronic carrier, the nurse should focus on blocking the portal of exit from the reservoir, which is the carrier person. By preventing the movement of the organism from the reservoir, the infection can be contained. Eliminating the reservoir is not feasible in this case as the carrier is a chronic carrier. Blocking the portal of entry into the host or decreasing the susceptibility of the host would only impact individual prevention and not the spread from the carrier to others.
4. A patient's Foley catheter has been discontinued. You will dispose of this patient equipment by doing which of the following?
- A. Wearing gloves and then placing this equipment in the regular trash can after it is placed in a paper bag.
- B. Simply placing this equipment in the regular trash can after it is placed in a paper bag.
- C. Wearing gloves and then placing this equipment into a special 'hazardous waste' container.
- D. Simply placing this equipment in the 'hazardous waste' container after it is placed in a paper bag.
Correct answer: C
Rationale: When disposing of used patient equipment, such as a Foley catheter, that has come in contact with bodily fluids, it is considered hazardous waste. The correct procedure involves wearing gloves and placing the Foley bag and tubing into a special 'hazardous waste' container. This container is marked as 'Hazardous' and is typically red to indicate the potential danger of its contents. Placing the equipment in a regular trash can, even if placed in a paper bag, is not appropriate as it does not meet the standards for disposing of hazardous waste. Therefore, options A and B are incorrect. Similarly, simply placing the equipment in a 'hazardous waste' container after it is placed in a paper bag is also incorrect as direct disposal into the designated container while wearing gloves is the proper protocol, making option D incorrect.
5. A patient has a goal of eating at least 50% of each meal. The patient refuses to eat, so a nurse force-feeds the patient in order for them to reach their goal of eating at least 50% of the meal. The nurse has committed __________ against this patient.
- A. assault
- B. battery
- C. physical neglect
- D. emotional neglect
Correct answer: B
Rationale: The correct answer is 'battery.' Battery occurs when there is unwanted physical contact or force applied to a person without their consent. In this scenario, force-feeding the patient against their will constitutes battery as the nurse is physically interfering with the patient's body without permission. Assault involves the threat of physical harm, which is not present in the situation described. Physical neglect refers to the failure to provide basic care needs, which is not the case here. Emotional neglect involves the failure to address emotional needs, which is also not applicable in this context.
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