NCLEX-RN
NCLEX RN Predictor Exam
1. During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?
- A. Ask the patient how he or she is feeling.
- B. Document the findings in the patient's record.
- C. Wait 10 minutes and auscultate the sound again.
- D. Ask another nurse to double-check the finding.
Correct answer: D
Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.
2. For a patient who is blood type AB, which blood product can they receive?
- A. Plasma from a type B donor
- B. Whole blood from a type A donor
- C. Packed RBCs from a type O donor
- D. All of the above
Correct answer: C
Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens. Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma. Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens. Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type. Therefore, choices A and B are incorrect, and the correct choice is C.
3. The healthcare professional is preparing to auscultate the abdomen. How should they proceed?
- A. Warm the endpiece of the stethoscope by rubbing it between their hands.
- B. Ensure the patient is adequately covered and comfortable during the examination.
- C. Ensure that the diaphragm side of the stethoscope is in use.
- D. Check the room temperature and offer blankets to the patient if needed.
Correct answer: D
Rationale: When preparing to auscultate the abdomen, it is important to ensure the patient's comfort. The room should be warm to prevent shivering, which can interfere with sound clarity. Offering blankets to the patient if they feel cold helps maintain their comfort during the examination. The endpiece of the stethoscope should be warmed by rubbing it between the examiner's hands, not by placing it in warm water. It is important to use the diaphragm, not the bell, of the stethoscope to auscultate for bowel sounds. Therefore, choice D is the correct answer, as it addresses the patient's comfort and the room temperature, which are essential for a successful abdominal auscultation.
4. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?
- A. Get the nurse who is caring for the patient.
- B. Tell the nurse that the patient has had another seizure.
- C. Observe the patient for any injuries and call out for help.
- D. Nothing. This patient is not one of your assignments.
Correct answer: C
Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.
5. The abbreviation ac is defined as _____________.
- A. before the meal
- B. with the meal
- C. after the meal
- D. ante cibum
Correct answer: A
Rationale: The correct answer is 'before the meal.' The abbreviation 'ac' is derived from the Latin term 'ante cibum,' which translates to 'before a meal.' Choices B, C, and D are incorrect because 'ac' does not refer to 'with the meal,' 'after the meal,' or 'ante corpis.' It specifically denotes something occurring before a meal, making option A the correct choice in this context.
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