NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, "My blood pressure is usually much lower."? The nurse should tell the client to:
- A. Go get a blood pressure check within the next 15 minutes
- B. Check blood pressure again in two (2) months
- C. See the healthcare provider immediately
- D. Visit the healthcare provider within one (1) week for a BP check
Correct answer: A
Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke. Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (Choice B) or a week (Choice D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (Choice C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.
2. Which risk factor places patients and residents at the greatest risk for falls?
- A. Old age
- B. Middle age
- C. Pneumonia
- D. COPD
Correct answer: A
Rationale: Old age is a significant risk factor for falls as elderly individuals are more prone to falls due to factors like decreased balance, muscle strength, and vision. Middle age is less associated with falls compared to old age. Pneumonia and COPD are medical conditions that are not direct risk factors for falls, unlike aging which significantly increases the risk of falls.
3. Which of the following statements is true regarding non-profit organizations?
- A. They are located in various areas, not specifically poor or rural ones.
- B. They are mandated to care for people, even if clients are unable to pay for services.
- C. The money they receive for services is reinvested back into their own business to further develop services.
- D. They are not referred to as proprietary organizations.
Correct answer: B
Rationale: Non-profit organizations are entities that operate for a social cause or public benefit, and they do not distribute profits to owners or shareholders. They are not limited to being located in poor or rural areas; they can be found in various locations. One key characteristic of non-profits is that they are obligated to provide services, regardless of a client's ability to pay. This ensures that essential services are accessible to all individuals in need. The statement 'The money they receive for services is reinvested back into their own business to further develop services' is correct. Non-profit organizations reinvest any surplus funds back into their operations to enhance the services they provide. The statement 'They are not referred to as proprietary organizations' is correct because proprietary organizations are typically for-profit entities, not non-profit ones.
4. Which of the following is a true statement about assessing blood pressure by palpation?
- A. Only the diastolic blood pressure can be assessed through palpation.
- B. The palpation technique is most useful for infants and small children.
- C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
- D. Only the systolic blood pressure can be assessed through palpation.
Correct answer: D
Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.
5. In a clinic in a primarily African American community, a higher incidence of uncontrolled hypertension is noted in patients. To correct this health disparity, what should the nurse do first?
- A. Initiate a regular home-visit program by clinic nurses.
- B. Schedule teaching sessions about low-salt diets at community events.
- C. Assess the perceptions of community members about the care at the clinic.
- D. Obtain low-cost antihypertensive drugs using government grant funding.
Correct answer: C
Rationale: To address the higher incidence of uncontrolled hypertension in the primarily African American community, the nurse should first assess the perceptions of community members about the care at the clinic. Understanding the community's perspective can provide valuable insights into the reasons behind the health disparity. Initiating a regular home-visit program or scheduling teaching sessions about low-salt diets are important interventions but should come after gathering information on community perceptions. Obtaining low-cost antihypertensive drugs is not the initial priority; understanding community perspectives is crucial for developing effective interventions.
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