NCLEX-RN
NCLEX RN Predictor Exam
1. Efforts by healthcare facilities to reduce the incidence of hospital-acquired infections (HAIs) include an awareness of which of the following?
- A. The CDC requires all states to report HAI rates from each hospital.
- B. Ensure that the restraints are tied to the side rails.
- C. The gastrointestinal tract is a common site for HAIs.
- D. Joint Commission considers death or serious injury from HAIs a sentinel event.
Correct answer: D
Rationale: Efforts to reduce hospital-acquired infections (HAIs) involve being aware that the Joint Commission considers death or serious injury resulting from HAIs a sentinel event, which must be reported. While more than 20 states require reporting of HAI rates to the CDC, it is not a nationwide CDC requirement. The gastrointestinal tract is not a specific common site for HAIs; rather, bacteria are the primary cause. Ensuring restraints are properly secured is important for patient safety but not directly related to reducing HAIs.
2. A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?
- A. Allow 5 minutes for the student to relax and rest before checking their vital signs.
- B. Check the blood pressure in both arms, expecting a difference in the readings due to the recent exercise.
- C. Immediately monitor the student's vital signs upon arrival at the clinic and then 5 minutes later, recording any differences.
- D. Check the student's blood pressure in the supine position to provide a more accurate reading and allow the student to relax at the same time.
Correct answer: A
Rationale: To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.
3. A patient suffering from hyperglycemia would be experiencing:
- A. Low blood sugar
- B. High blood sugar
- C. Normal blood sugar
- D. None of the above
Correct answer: B
Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.
4. Nursing care plans contain which of the following?
- A. nursing diagnoses
- B. medical diagnoses.
- C. MD orders.
- D. intake and output forms
Correct answer: A
Rationale: Nursing care plans are legal documents that contain nursing diagnoses, such as an "Alteration of respiratory function". They also contain patient goals and nursing interventions.
5. While measuring a patient's blood pressure, which factor influences a patient's blood pressure?
- A. Pulse rate
- B. Pulse pressure
- C. Vascular output
- D. Peripheral vascular resistance
Correct answer: D
Rationale: When measuring a patient's blood pressure, it is important to consider various factors that influence blood pressure. Peripheral vascular resistance plays a crucial role in regulating blood pressure. The level of blood pressure is affected by factors such as cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls. Pulse rate (Choice A) refers to the number of heartbeats per minute and is not a primary factor influencing blood pressure. Pulse pressure (Choice B) is the difference between systolic and diastolic blood pressure and does not directly impact blood pressure regulation. Vascular output (Choice C) is not a recognized term in blood pressure regulation and is not a primary factor affecting blood pressure.
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