NCLEX-RN
NCLEX RN Predictor Exam
1. When are manual hematocrits done?
- A. to monitor anemia
- B. by using a microhematocrit tube.
- C. to measure the percentage of plasma to cells.
- D. All of the above.
Correct answer: D
Rationale: Manual hematocrits are performed to monitor anemia, which involves measuring the percentage of red blood cells in the blood. The process involves collecting blood in a microhematocrit tube, then centrifuging it to separate the plasma from the cells. By measuring the ratio of plasma to cells, healthcare providers can assess the patient's hematocrit level. Therefore, all the provided options are correct as they collectively describe the purpose and procedure of manual hematocrits.
2. A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process?
- A. Use sterile solution at room temperature
- B. Position the client in a comfortable position
- C. Clamp the catheter at the level above the injection port
- D. Inject sterile solution through the injection port into the catheter
Correct answer: D
Rationale: When performing closed intermittent system catheter irrigation, the nurse should use sterile solution at room temperature with sterile technique. It is important to position the client comfortably for easy access to the catheter site and to assess the abdomen during the procedure. Clamping the catheter should be done below the level of the injection port, not above. The correct step is to inject sterile solution through the injection port into the catheter, allowing the fluid to travel up the catheter to irrigate the tubing and the bladder.
3. After taking the vital signs for your patient and finding them to be normal, what should you do next?
- A. Report the vital signs to the doctor
- B. Write the vital signs on a scrap paper
- C. Call the family members
- D. Document them on the graphic VS form
Correct answer: D
Rationale: After assessing and finding that the vital signs are normal for the patient, the appropriate action would be to document them on the graphic VS form. This form is used to track and record vital sign measurements accurately and consistently. Reporting the normal vital signs to the doctor is not necessary unless there are concerning trends or deviations. Writing the vital signs on a scrap piece of paper is not recommended as it may not be an official or reliable record. Calling the family members is unrelated to the process of documenting and tracking vital signs for the patient.
4. In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Universal precautions
Correct answer: A
Rationale: Rubella is an illness transmitted by large-particle droplets, so the nurse should implement droplet precautions in addition to standard precautions. Airborne precautions are used for diseases spread through small particles in the air, such as tuberculosis, varicella, and rubeola. Contact precautions are utilized for diseases transmitted by direct contact with the patient or their environment. Universal precautions and body substance isolations are part of the CDC's standard precautions recommendations, but do not specifically address the transmission route of rubella.
5. When performing an EKG, the patient starts to laugh out of feelings of anxiety. What would you expect the EKG to show? (Choose the BEST answer.)
- A. Increased pulse rate, normal EKG
- B. Decreased pulse rate, abnormal EKG
- C. Tachycardia, poor EKG graph
- D. Bradycardia, poor EKG graph
Correct answer: C
Rationale: When a patient laughs due to anxiety during an EKG, it is likely to cause tachycardia, which is a rapid heart rate. This increased heart rate can lead to poor EKG graph quality as the electrical signals from large moving muscles can interfere with data collection from the chest leads. Therefore, in this scenario, the EKG is expected to show tachycardia with poor graph quality. Choices A, B, and D are incorrect because a patient laughing out of anxiety is more likely to result in an increased pulse rate (tachycardia) rather than a decreased pulse rate (bradycardia) or a normal EKG.
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