NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Patients exhibiting signs of cyanosis will:
- A. show signs of hyperoxia.
- B. have increased O2 saturation.
- C. have blood levels of CO2 higher than O2 levels.
- D. None of the above.
Correct answer: C
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from low blood oxygen levels. When a patient exhibits cyanosis, it indicates that their blood is poorly oxygenated, leading to a higher concentration of CO2 compared to oxygen. Options A and B are incorrect as cyanosis is associated with low oxygen levels, not hyperoxia or increased O2 saturation. Therefore, the correct answer is that patients exhibiting cyanosis will have blood levels of CO2 higher than O2 levels.
2. A urine pregnancy test:
- A. May be negative even if a blood pregnancy test is positive.
- B. Is positive only during the first trimester of pregnancy.
- C. Will be negative if the amount of LH isn't enough to meet or exceed the sensitivity of the testing device.
- D. All of the above.
Correct answer: A
Rationale: A urine pregnancy test detects HCG in a pregnant woman's urine. Blood levels of HCG are usually higher and register earlier than HCG levels in the urine. Choice A is correct because urine pregnancy tests may be negative even if a blood pregnancy test is positive due to the differences in HCG levels in blood and urine. Choice B is incorrect because a urine pregnancy test can be positive throughout pregnancy, not just in the first trimester. Choice C is incorrect because LH (luteinizing hormone) is not the hormone detected in a pregnancy test; it is HCG (human chorionic gonadotropin). Choice D is incorrect because not all the statements provided are true.
3. You are working the 8 am to 4 pm shift. You begin to vomit at 3 pm and you do not think that you are able to continue working. You decide to immediately go home without notifying your RN supervisor. You have ________________.
- A. enough sick time, so this is not a problem.
- B. finished all your work, so this is not a problem.
- C. seriously abandoned the patients.
- D. seriously abused and neglected the patients.
Correct answer: D
Rationale: Patient abandonment is a serious violation that can lead to disciplinary action and immediate termination of employment. It is defined as leaving patients without proper consent from the supervisor. In this scenario, leaving work without notifying the RN supervisor and potentially leaving patients unattended is considered patient abandonment, as it compromises patient safety and care. Choices A and B are incorrect because having sick time or finishing work does not justify leaving without proper protocol. Choice D is incorrect as the scenario does not indicate abuse or neglect towards the patients.
4. A client's intake and output are being calculated by a nurse. During the last shift, the client consumed � cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client also urinated 250 cc and had 2 bowel movements. What is this client's intake and output for this shift?
- A. 420 cc intake, 250 cc output
- B. 300 cc intake, 250 cc output
- C. 550 cc intake, 550 cc output
- D. 300 cc intake, 550 cc output
Correct answer: A
Rationale: The correct answer is 420 cc intake and 250 cc output for this shift. To calculate the intake, � cup of gelatin (approximately 120 cc) and 300 cc of water should be added together, resulting in 420 cc. Food intake like the chicken breast and green beans is not converted to cc's but may be documented for hospital protocol. Output includes urine (250 cc in this case) and other forms like vomit, diarrhea, or gastric suction. Bowel movements are not converted to cc's, but the nurse may need to document the number of stools passed. Choices B, C, and D are incorrect because they do not accurately reflect the intake and output calculations based on the information provided.
5. Where is the duodenum located in the digestive system?
- A. It is the first part of the small intestine, located immediately after the stomach.
- B. It is the section of the digestive system where the gall bladder delivers bile.
- C. It is the section of the small intestine where the pancreas delivers digestive juices.
- D. None of the above.
Correct answer: D
Rationale: The duodenum is the first part of the small intestine, located immediately after the stomach. It is where the majority of digestion takes place in the gut. The pancreas delivers digestive juices containing amylase and lipase, while the gall bladder delivers bile to aid in the digestion of fats. Choice A incorrectly states that the duodenum is the third section of the small intestine, which is inaccurate. Choice B incorrectly associates the duodenum with the gall bladder, which is not where the duodenum is located. Choice C incorrectly states that the duodenum is where the pancreas delivers digestive juices, which is partly correct but not the main function of the duodenum. Therefore, the correct answer is 'None of the above' as none of the choices accurately describe the location or functions of the duodenum.
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