NCLEX-RN
NCLEX RN Exam Prep
1. 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.
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. The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?"? Which critique of the nurse's technique is most accurate?
- A. Asking questions may enhance the child's autonomy.
- B. Asking the child for permission helps develop a sense of trust.
- C. This question is an inappropriate statement because children at this age like to have choices.
- D. Children at this age like to say, "No."? The examiner should not offer a choice when no choice is available.
Correct answer: D
Rationale: Children at the age of 2 often like to assert their independence by saying "No."? In situations where there is actually no choice available, offering a false choice can lead to a lack of trust. It is important not to offer a choice when there isn't one, as doing so may undermine trust. While asking for permission can enhance autonomy and trust, offering a limited option like, "Shall I listen to your heart next or your tummy?"? may be a better approach. Therefore, the correct critique of the nurse's technique in this scenario is that children at this age tend to say "No,"? so the examiner should avoid offering a choice when there isn't a real alternative.
4. What does the medical term 'basophilia' refer to?
- A. An attachment of the epithelial cells of the skin to a basement membrane
- B. An overabundance of a particular white blood cell in the peripheral blood
- C. An underrepresentation of basophils on a blood smear
- D. None of the above
Correct answer: B
Rationale: The correct answer is 'An overabundance of a particular white blood cell in the peripheral blood.' Basophilia specifically indicates an increased number of basophils in the peripheral blood. It can be observed in conditions like leukemia and certain allergic reactions. Choice A is incorrect as it describes something unrelated to basophilia. Choice C is incorrect as it suggests a decrease in basophils, which is opposite to the actual meaning of basophilia. Choice D is also incorrect as basophilia does have a defined medical significance.
5. A patient is asked to abduct her arms. Which of the following accurately describes her arm movement?
- A. She moves her arms away from her trunk
- B. She moves her arms toward her trunk
- C. She rotates her arms at the wrists while holding them away from her body
- D. She crosses her arms over her abdomen
Correct answer: A
Rationale: Abduction refers to moving a body part away from the midline of the body. In this case, when the patient abducts her arms, she is moving them away from her trunk. Choice A is correct. Choices B, C, and D are incorrect. Choice B describes adduction, which is the movement of a body part toward the midline. Choice C describes wrist rotation, not arm abduction. Choice D describes crossing the arms over the abdomen, which is not the movement associated with abduction.
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