NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. In the term 'Hemoglobin,' the suffix '-globin' means:
- A. Protein
- B. Iron
- C. Metal
- D. Blood
Correct answer: A
Rationale: The suffix '-globin' in the term 'Hemoglobin' specifically refers to a protein. Hemoglobin is a protein found in red blood cells that carries oxygen. Choice B, 'Iron,' is incorrect as iron is a mineral component of hemoglobin but not the meaning of the suffix. Choice C, 'Metal,' is too broad and not specific to the meaning of the suffix in this context. Choice D, 'Blood,' is incorrect as it refers to the overall term 'Hemoglobin' rather than the specific meaning of the suffix '-globin.' Therefore, the correct answer is A: 'Protein.'
2. A client in a long-term care facility has developed reddened skin over the sacrum, which has cracked and started to blister. The nurse confirms that the client has not been assisted with turning while in bed. Which stage of pressure ulcer is this client exhibiting?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct answer: B
Rationale: The client is exhibiting a stage II pressure ulcer. A stage II pressure ulcer develops as a partial thickness wound that affects both the epidermis and the dermal layers of skin. This stage can present with red skin, blisters, or cracking, appearing shallow and moist. However, the ulcer does not extend to the underlying tissues at this stage. Choice A (Stage I) is incorrect as Stage I ulcers involve non-blanchable redness of intact skin. Choices C (Stage III) and D (Stage IV) are incorrect as they involve more severe tissue damage, extending into deeper layers of the skin and underlying tissues, which is not the case in this scenario.
3. When should you wear gloves?
- A. preparing infant formula for a newborn baby
- B. transferring breast milk into a baby bottle
- C. knocking on a patient's door
- D. opening a patient's door
Correct answer: B
Rationale: You must wear gloves when transferring breast milk into a baby bottle because breast milk is considered a bodily fluid. It is essential to avoid direct contact to prevent contamination. When preparing infant formula, gloves are not required as formula is not a bodily fluid. Knocking on or opening a patient's door does not involve direct contact with bodily fluids, so gloves are unnecessary in those situations.
4. Which technique is correct when assessing the radial pulse of a patient?
- A. Palpate for 1 minute if the rhythm is irregular.
- B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
- C. Palpate for 2 full minutes to detect any variation in amplitude.
- D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.
Correct answer: A
Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.
5. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?
- A. A little, a moderate amount, or all of the meal
- B. 50 cc, 100 cc, or 500 cc of the meal
- C. 25%, 50%, or 100% of the meal
- D. Either A or C
Correct answer: C
Rationale: Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate. Choices A and B are incorrect. Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation. Choice B's use of cc is more appropriate for measuring fluids, not solid foods. Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.
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