NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. The mitral valve is synonymous with the term:
- A. Left ventricle
- B. Right atrium
- C. Bicuspid valve
- D. Tricuspid valve
Correct answer: C
Rationale: The mitral valve, also known as the bicuspid valve, is located between the left atrium and the left ventricle, regulating blood flow from the left atrium into the left ventricle. The term 'bicuspid' refers to the valve's two cusps or leaflets. This distinguishes it from the tricuspid valve (Choice D), which has three cusps, making Choice D incorrect. The left ventricle (Choice A) and right atrium (Choice B) are not synonymous with the mitral valve. Therefore, the correct answer is C: Bicuspid valve.
2. When cleansing the genital area during perineal care, the nurse should _____________.
- A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
- B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
- C. cleanse the rectal area first and then clean the patient's genital area.
- D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.
Correct answer: B
Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.
3. Intermittent fevers are:
- A. fevers which come and go.
- B. fevers which rise and fall but are always considered above the patient's average temperature.
- C. fevers which fluctuate more than three degrees and never return to normal.
- D. None of the above.
Correct answer: A
Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.
4. The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?"? Which critique of the nurse's technique is most accurate?
- A. Asking questions may enhance the child's autonomy.
- B. Asking the child for permission helps develop a sense of trust.
- C. This question is an inappropriate statement because children at this age like to have choices.
- D. Children at this age like to say, "No."? The examiner should not offer a choice when no choice is available.
Correct answer: D
Rationale: Children at the age of 2 often like to assert their independence by saying "No."? In situations where there is actually no choice available, offering a false choice can lead to a lack of trust. It is important not to offer a choice when there isn't one, as doing so may undermine trust. While asking for permission can enhance autonomy and trust, offering a limited option like, "Shall I listen to your heart next or your tummy?"? may be a better approach. Therefore, the correct critique of the nurse's technique in this scenario is that children at this age tend to say "No,"? so the examiner should avoid offering a choice when there isn't a real alternative.
5. When a sequence of repeated weights is necessary, the healthcare provider should aim to weigh the patient at the same time of day and with consistent clothing. Using a standardized balance or electronic standing scale is recommended for accurate measurements. The patient should remove shoes and heavy outer clothing. It is not required for the patient to always be weighed in undergarments. What is the most appropriate indicator of the patient's overall well-being?
- A. General health
- B. Genetic makeup
- C. Nutritional status
- D. Activity and exercise patterns
Correct answer: A
Rationale: Weight measurements are essential to assess general health, particularly in monitoring growth patterns. Height and weight recordings are crucial indicators of overall well-being, reflecting the individual's health status. Genetic makeup does not change with weight fluctuations, making it an inappropriate indicator. Nutritional status and activity levels can influence weight but are not as comprehensive as general health in reflecting overall well-being.
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