NCLEX-RN
NCLEX RN Exam Prep
1. What does preload refer to?
- A. The volume of blood entering the left side of the heart
- B. The volume of blood entering the right side of the heart
- C. The pressure in the venous system that the heart must overcome to pump the blood
- D. The pressure in the arterial system that the heart must overcome to pump the blood
Correct answer: B
Rationale: Preload refers to the volume of blood that enters the right side of the heart. This volume stretches the fibers in the heart before contraction. Preload is an essential factor in determining the force of ventricular contraction. Choices A, C, and D are incorrect. Choice A is incorrect because preload is specifically related to the volume of blood entering the right side of the heart. Choices C and D are incorrect as they refer to afterload, which is the pressure that the heart must overcome to pump blood out of the ventricles into the systemic or pulmonary circulation.
2. What is the flap of tissue that covers the trachea upon swallowing called?
- A. Epidermis
- B. Endocardium
- C. Epiglottis
- D. Epistaxis
Correct answer: C
Rationale: The correct answer is C: Epiglottis. The epiglottis is a flap of tissue that covers the trachea when swallowing to prevent food or liquid from entering the airway. Choice A, Epidermis, is the outer layer of the skin and is not related to the trachea. Choice B, Endocardium, is the inner lining of the heart chambers and is also unrelated to the trachea. Choice D, Epistaxis, refers to a nosebleed and is not the correct term for the tissue covering the trachea.
3. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?
- A. Help client into the chair more quickly
- B. Document client's vital signs taken just prior to moving the client
- C. Help client back to bed immediately
- D. Observe client's skin color and take another set of vital signs
Correct answer: D
Rationale: In this scenario, the nurse has observed concerning signs in the client during the transfer process. The appropriate action for reassessment would be to observe the client's skin color and take another set of vital signs. This will provide essential data to evaluate the client's condition more accurately. Options A, B, and C are interventions that do not address the need for reassessment. Moving the client more quickly, documenting previous vital signs, or returning the client to bed do not directly address the need to reassess the client's current condition.
4. Which term best describes changes such as retirement, grandparenting, and increased dependence on others?
- A. Moral
- B. Psychosocial
- C. Self-esteem
- D. Psychomotor
Correct answer: B
Rationale: The correct answer is 'Psychosocial.' Retirement, grandparenting, and increased dependence on others are examples of psychosocial changes because they involve social interactions, relationships, and psychological aspects. 'Moral' (Choice A) does not directly relate to the changes mentioned. 'Self-esteem' (Choice C) is more about self-perception and confidence, not the social changes mentioned. 'Psychomotor' (Choice D) refers to physical movements and skills, which are not the focus of the changes described in the question.
5. After change-of-shift report, which patient should the nurse assess first?
- A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
- B. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C)
- C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
- D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
Correct answer: D
Rationale: The patient with lung cancer and tracheal deviation after a subclavian catheter insertion should be assessed first. Tracheal deviation can indicate tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent inadequate cardiac output or hypoxemia. While the other patients also need assessment, the potential for tension pneumothorax in the patient with tracheal deviation necessitates urgent attention to prevent complications.
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