NCLEX-RN
NCLEX RN Predictor Exam
1. The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.
- A. Client has an actual health problem
- B. Client has a wellness diagnosis
- C. Collaborative health problem needs to be written
- D. Possible nursing diagnosis exists
Correct answer: B
Rationale: The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.
2. During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?
- A. Ask the patient how he or she is feeling.
- B. Document the findings in the patient's record.
- C. Wait 10 minutes and auscultate the sound again.
- D. Ask another nurse to double-check the finding.
Correct answer: D
Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.
3. The Atlas and the Axis are:
- A. found in the vertebrae.
- B. described as being cervical.
- C. the first two bones that form the column for the spine on the superior aspect.
- D. All of the above.
Correct answer: D
Rationale: The Atlas and the Axis are the first two cervical vertebrae, designated as C1 and C2. The Atlas (C1) supports the skull, while the Axis (C2) allows for rotation of the skull. Therefore, all the statements in choices A, B, and C are correct, making 'All of the above' the correct answer. Choice A is correct as the Atlas and Axis are indeed found in the vertebrae. Choice B is correct as they are the first two cervical vertebrae. Choice C is correct as these bones form the superior aspect of the spine.
4. What is the primary purpose of a patient care meeting or conference?
- A. the patient's ability to pay for the costs of their care
- B. how the healthcare team can best meet the patient's needs
- C. the patient's physical status and condition
- D. the patient's psychosocial status and condition
Correct answer: B
Rationale: The primary purpose of a patient care meeting or conference is to determine how the healthcare team can best meet the patient's needs. These meetings involve discussions among healthcare professionals to tailor the care plan to the specific needs and preferences of the patient. Option A is incorrect because financial discussions are generally not the primary focus of patient care meetings. Option C is incorrect as the patient's physical status is usually already known and is not the primary purpose of the meeting. Option D is incorrect as psychosocial aspects, while important, are not the sole focus of the meeting, which is primarily about addressing the patient's overall needs and preferences.
5. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?
- A. "Ethnicity is dynamic and ever-changing."?
- B. "Ethnicity is the belief in a higher power."?
- C. "Ethnicity pertains to a social group that may possess shared traits such as religion and language."?
- D. "Ethnicity is learned from birth through the processes of language acquisition and socialization."?
Correct answer: C
Rationale: Ethnicity pertains to a social group that may possess shared traits such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Culture is dynamic, ever-changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power. Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.
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