NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. 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.
2. Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.
- A. Client and Family
- B. Other nursing staff on the unit
- C. Security department
- D. Hospital administration
Correct answer: B
Rationale: Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.
3. During the general survey, what action is a component of the assessment?
- A. Observing the patient's body stature and nutritional status
- B. Interpreting the subjective information reported by the patient
- C. Measuring the patient's temperature, pulse, respirations, and blood pressure
- D. Observing specific body systems during the physical assessment
Correct answer: A
Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.
4. Your patient who had AIDS/HIV has just died. Should you still use standard precautions as you provide post-mortem care?
- A. Yes, because the virus is still transmissible
- B. Yes, because respect must still be maintained
- C. No, because the virus is no longer transmissible
- D. No, because it is disrespectful
Correct answer: A
Rationale: Yes, you should still use standard precautions even after an HIV/AIDS patient has died. The virus can remain infectious after death, and healthcare workers need to protect themselves from potential exposure. Choice B is incorrect because while respect is important, the primary reason for using standard precautions is to prevent transmission of infectious diseases. Choice C is incorrect as the virus can still be transmissible even after the patient's death. Choice D is incorrect as using standard precautions is a matter of infection control, not a question of respect.
5. What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?
- A. The popliteal artery should be auscultated to obtain thigh pressure.
- B. The best position to measure thigh pressure is the prone position.
- C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
- D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.
Correct answer: C
Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.
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