NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. The abbreviation ac is defined as _____________.
- A. before the meal
- B. with the meal
- C. after the meal
- D. ante cibum
Correct answer: A
Rationale: The correct answer is 'before the meal.' The abbreviation 'ac' is derived from the Latin term 'ante cibum,' which translates to 'before a meal.' Choices B, C, and D are incorrect because 'ac' does not refer to 'with the meal,' 'after the meal,' or 'ante corpis.' It specifically denotes something occurring before a meal, making option A the correct choice in this context.
2. During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?
- A. Constipation
- B. Air-filled areas
- C. Presence of a tumor
- D. Presence of dense organs
Correct answer: B
Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.
3. During a client interview, which of the following leading questions should the nurse avoid asking?
- A. What medication do you take at home?
- B. You are really excited about the plastic surgery, aren't you?
- C. Were you aware I've had this same type of surgery?
- D. What would you like to talk about?
Correct answer: B
Rationale: The nurse should avoid asking leading questions during a client interview as they can influence the client's response. Option B is a leading question as it suggests an expected response from the client, potentially biasing the information provided. This can lead to inaccurate data collection and subsequent errors in diagnostic reasoning. Choices A, C, and D are open-ended questions that encourage the client to provide unbiased information and allow for a more comprehensive assessment.
4. During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?
- A. 40-year-old with chronic pancreatitis who has gnawing abdominal pain
- B. 58-year-old who has compensated cirrhosis and is complaining of anorexia
- C. 55-year-old with cirrhosis and ascites who has an oral temperature of 102�F (38.8�C)
- D. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain
Correct answer: C
Rationale: When prioritizing patient assessments, the nurse should address the patient with cirrhosis and ascites who has an elevated oral temperature of 102�F (38.8�C) first. This presentation suggests a potential infection, which is critical to address promptly in a patient with liver disease. An infection in a patient with cirrhosis can quickly progress to severe complications. The other options, such as chronic pancreatitis with abdominal pain, compensated cirrhosis with anorexia, and post-laparoscopic cholecystectomy with shoulder pain, do not indicate an immediate life-threatening situation requiring urgent assessment compared to a possible infection in a patient with cirrhosis and ascites.
5. A patient is bleeding profusely from an injury near her wrist. Which of the following first aid procedures would be MOST appropriate?
- A. Place a tourniquet on her arm above the injury.
- B. Place pressure on her brachial artery.
- C. Place pressure on her radial nerve.
- D. Cover the bleeding area with wet towels.
Correct answer: B
Rationale: The most appropriate first aid procedure for a patient bleeding profusely from an injury near the wrist is to place pressure on her brachial artery. Applying pressure to the brachial pulse point will help slow down the bleeding. Placing a tourniquet on her arm above the injury is not recommended as it could potentially inhibit blood flow, leading to tissue necrosis. Pressing on the radial nerve or covering the bleeding area with wet towels are not effective in controlling bleeding and may not address the underlying cause.
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