NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. The abbreviation pc is defined as ________________.
- A. before the meal
- B. with the meal
- C. after the meal
- D. post corpi
Correct answer: C
Rationale: The correct answer is C: 'after the meal.' In medical terminology, 'pc' is an abbreviation for 'post cibum,' which means 'after eating' or 'after the meal.' This term is used to indicate when a medication should be taken concerning meals. Choices A, B, and D are incorrect. 'Before the meal' (A) is typically abbreviated as 'ac,' 'with the meal' (B) is abbreviated as 'pc,' and 'post corpi' (D) is not a valid medical abbreviation or term.
2. A client in a long-term care facility has developed reddened skin over the sacrum, which has cracked and started to blister. The nurse confirms that the client has not been assisted with turning while in bed. Which stage of pressure ulcer is this client exhibiting?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct answer: B
Rationale: The client is exhibiting a stage II pressure ulcer. A stage II pressure ulcer develops as a partial thickness wound that affects both the epidermis and the dermal layers of skin. This stage can present with red skin, blisters, or cracking, appearing shallow and moist. However, the ulcer does not extend to the underlying tissues at this stage. Choice A (Stage I) is incorrect as Stage I ulcers involve non-blanchable redness of intact skin. Choices C (Stage III) and D (Stage IV) are incorrect as they involve more severe tissue damage, extending into deeper layers of the skin and underlying tissues, which is not the case in this scenario.
3. A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?
- A. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.
- B. The patient should be directed to walk around the room and his blood pressure assessed after this activity.
- C. Blood pressure and pulse are assessed at the beginning and at the end of the examination.
- D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.
Correct answer: A
Rationale: Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.
4. A healthcare professional realizes after a patient has left the office that they forgot to document the patient's complaint of a sore throat. Which of the following choices would BEST correct the error?
- A. Pull out that page of the chart and rewrite it with the correct information.
- B. Put one line through the original Chief Complaint, write 'ERROR,' your initials, and today's date. Make the correction by rewriting the Chief Complaint with the correct information.
- C. Go to the next available line of the SOAP notes. Write the current date, then write 'Late Entry.' Place the date and time when the patient stated they had a sore throat. Sign and date the entry.
- D. All of the above are incorrect.
Correct answer: C
Rationale: When adding information to a patient's chart after the encounter, using the term 'Late Entry' is essential. This clearly indicates that the information was added after the fact and helps to maintain the accuracy and integrity of the medical record. Option A is incorrect because removing a page from the chart and rewriting it can lead to inaccuracies and is not a recommended practice for correcting errors. Option B suggests marking the original Chief Complaint as an error, which may not be clear to future readers of the chart and could lead to confusion. Option D is incorrect as it dismisses the correct approach outlined in Option C, which is the best way to handle the situation of missed documentation during a patient encounter.
5. What does the term 'Afferent Nerve' mean?
- A. Carrying an impulse to the brain
- B. Carrying an impulse away from the brain
- C. Carrying impulses to the motor neurons of the appendicular muscles
- D. None of the above
Correct answer: A
Rationale: The correct answer is 'Carrying an impulse to the brain.' Afferent nerves are sensory nerves that carry signals from sensory receptors towards the central nervous system, including the brain. Choice B, 'Carrying an impulse away from the brain,' is incorrect as this describes efferent nerves which carry signals from the central nervous system to muscles and glands. Choice C, 'Carrying impulses to the motor neurons of the appendicular muscles,' is incorrect as it describes a different type of nerve function. Choice D, 'None of the above,' is incorrect as the correct definition of afferent nerve is indeed 'Carrying an impulse to the brain.'
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