NCLEX-RN
NCLEX RN Exam Preview Answers
1. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?
- A. "Ethnicity is dynamic and ever-changing."?
- B. "Ethnicity is the belief in a higher power."?
- C. "Ethnicity pertains to a social group that may possess shared traits such as religion and language."?
- D. "Ethnicity is learned from birth through the processes of language acquisition and socialization."?
Correct answer: C
Rationale: Ethnicity pertains to a social group that may possess shared traits such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Culture is dynamic, ever-changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power. Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.
2. Which vacutainer tubes should be used when a requisition calls for blood to be drawn for an H&H and glucose test?
- A. One light blue, one red
- B. Two lavenders
- C. One lavender, one grey
- D. One green, one red
Correct answer: D
Rationale: The correct answer is 'One green, one red.' An H&H test involves hemoglobin and hematocrit, which are components of a complete blood count and are typically drawn in a lavender tube. On the other hand, blood for glucose testing is collected in grey tubes. Therefore, when drawing blood for both an H&H and glucose test, one green tube for glucose and one red tube for H&H should be used. The other choices are incorrect because light blue tubes are used for coagulation studies, lavender tubes are for complete blood counts, and green tubes are for chemistry tests like glucose, while grey tubes are specifically for glucose testing.
3. What is the initial step to take when a patient passes out at the front desk?
- A. Call 911.
- B. Initiate CPR.
- C. Shake the patient and ask if they are okay.
- D. Check for a pulse.
Correct answer: C
Rationale: The correct initial step when a patient passes out at the front desk is to shake the patient gently and ask if they are okay. This step aims to assess the patient's level of responsiveness. Checking for a pulse or initiating CPR should only be done if the patient does not respond to being shaken. Calling 911 can be the next step after assessing the patient's immediate condition and providing necessary assistance.
4. Why should a palpated pressure be performed before auscultating blood pressure?
- A. To more clearly hear the Korotkoff sounds.
- B. To detect the presence of an auscultatory gap.
- C. To avoid missing a falsely elevated blood pressure.
- D. To more readily identify phase IV of the Korotkoff sounds.
Correct answer: B
Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.
5. When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?
- A. Respirations are measured first, followed by pulse and temperature.
- B. Vital signs should be measured as frequently as in an adult.
- C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
- D. The nurse should first measure the infant's vital signs before performing a physical examination.
Correct answer: A
Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values. Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.
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