NCLEX NCLEX-RN
NCLEX RN Predictor Exam
1. A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?
- A. Run the urine on the hand-held glucometer.
- B. Have another MA perform a repeat dipstick test.
- C. Run a Clinitest.
- D. Run an Acetest.
Correct answer: Run a Clinitest.
Rationale: To confirm glucosuria, the most appropriate method is to run a Clinitest. Clinitest tablets are specifically designed to detect glucose in urine samples. This test is particularly useful when the urine is discolored, making it challenging to accurately assess the color change.\n Choice A, using a hand-held glucometer, is not the standard method for confirming glucose in urine; these devices are primarily used for blood glucose monitoring.\n Choice B, having another Medical Assistant perform a repeat dipstick test, may not provide a more definitive confirmation as dipstick tests can sometimes yield false positives or be less accurate compared to other methods like the Clinitest.\n Choice D, running an Acetest, is used to detect ketones in the urine, not glucose. Ketones are typically associated with conditions like diabetic ketoacidosis, which is different from glucosuria.
2. A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?
- A. Do you mean your boyfriend?
- B. Do you mean your boyfriend?
- C. No one will ever hurt you again.
- D. Tell me more about what happens when he gets angry.
Correct answer: Tell me more about what happens when he gets angry.
Rationale: The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.
3. A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?
- A. Wake the infant before beginning the examination.
- B. Examine the infant’s hips before the infant wakes up.
- C. Auscultate the lungs and heart while the infant is still sleeping.
- D. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
Correct answer: C: Auscultate the lungs and heart while the infant is still sleeping.
Rationale: When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant’s hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.
4. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the healthcare provider?
- A. Respirations are 36 breaths/minute.
- B. Anterior-posterior chest ratio is 1:1.
- C. Lung expansion is decreased bilaterally.
- D. Hyperresonance to percussion is present.
Correct answer: Respirations are 36 breaths/minute.
Rationale: The correct answer is 'Respirations are 36 breaths/minute.' An increased respiratory rate is a crucial sign of respiratory distress in patients with COPD, necessitating immediate interventions like oxygen therapy or medications. The other options are common chronic changes seen in COPD patients. Option B, the 'Anterior-posterior chest ratio is 1:1,' is related to the barrel chest commonly seen in COPD due to hyperinflation. Option C, 'Lung expansion is decreased bilaterally,' is expected in COPD due to air trapping. Option D, 'Hyperresonance to percussion is present,' is typical in COPD patients with increased lung volume and air trapping.
5. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals
- A. HBsAg.
- B. anti-HBs
- C. anti-HBc IgG
- D. anti-HBc IgM.
Correct answer: anti-HBs
Rationale: The correct answer is 'anti-HBs'. The presence of surface antibody to HBV (anti-HBs) indicates a successful response to the hepatitis B vaccine. Anti-HBs is a marker of immunity and protection against hepatitis B infection. Choices A, C, and D are incorrect because: A) HBsAg indicates current infection with hepatitis B virus, C) anti-HBc IgG suggests past infection or immunity, and D) anti-HBc IgM is a marker of acute hepatitis B infection.
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