NCLEX-RN
NCLEX RN Predictor Exam
1. To collect timely, specific information, the nurse is most likely to ask which of the following questions?
- A. Would you describe what you are feeling?
- B. How are you today?
- C. What would you like to talk about?
- D. Where does it hurt?
Correct answer: A
Rationale: The correct answer is, 'Would you describe what you are feeling?' This open-ended question prompts the patient to provide subjective data, offering specific information about their current health status and human responses. This information can help identify actual or potential health issues. Choices B and C are more likely to yield general, nonspecific information. Choice D may lead to a brief response or nonverbal indication of pain location. A more effective approach to gather specific information about pain would be to ask, 'Can you describe any pain you are experiencing?'
2. The healthcare provider is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?
- A. Usually yields little information
- B. Takes time and reveals a surprising amount of information
- C. May be somewhat uncomfortable for the expert practitioner
- D. Requires a thorough examination of the patient's body before proceeding with palpation
Correct answer: B
Rationale: During the inspection phase of a physical assessment, it is essential to take time as it can reveal a significant amount of information. Initially, it may feel uncomfortable for the examiner to focus solely on observing the patient without immediate action. Rushing through inspection is not recommended as it can lead to missing important cues. Train yourself to be thorough during inspection by observing carefully and taking the time needed to gather essential data. Choices A, C, and D are incorrect because inspection typically provides valuable information, may feel uncomfortable at first but is necessary for a comprehensive assessment, and does not involve a quick glance but requires a focused and detailed observation.
3. For a patient who is blood type AB, which blood product can they receive?
- A. Plasma from a type B donor
- B. Whole blood from a type A donor
- C. Packed RBCs from a type O donor
- D. All of the above
Correct answer: C
Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens. Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma. Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens. Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type. Therefore, choices A and B are incorrect, and the correct choice is C.
4. What is a common error when taking a pulse?
- A. Placing the index finger on the radial artery located on the thumb side of a patient's wrist.
- B. Noting a pulse as 'weak' when the pulsation disappears upon adding pressure.
- C. Counting the pulse for 15 seconds and multiplying the number by four.
- D. None of the above will cause errors.
Correct answer: C
Rationale: The correct answer is counting the pulse for 15 seconds and multiplying the number by four. To accurately assess a patient's heart rate or pulse, it is crucial to count the pulse for a full minute. Counting for only 15 seconds and then multiplying by four may result in an inaccurate heart rate calculation. This approach could miss arrhythmias or intermittent pulsations that could be vital indicators of the patient's condition. Placing the index finger on the radial artery, which is located on the thumb side of the patient's wrist, is the correct technique for taking a pulse. Noting a pulse as 'weak' when the pulsation disappears upon adding pressure is a valid observation and not an error in itself. Therefore, the most common error in this scenario is incorrectly calculating the pulse rate by multiplying a 15-second count by four.
5. When assessing the force or strength of a pulse, what would the nurse recall about the pulse?
- A. Is a reflection of the heart's stroke volume
- B. Typically recorded on a 0- to 3-point scale
- C. Demonstrates elasticity of the blood vessel wall
- D. Reflects the blood volume in the arteries during diastole
Correct answer: A
Rationale: When assessing the force or strength of a pulse, the nurse should recall that it is a reflection of the heart's stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta, causing arterial walls to flare and generate a pressure wave felt as the pulse in the periphery. The force of the pulse is typically recorded on a 0- to 3-point scale, not a 0- to 2-point scale. The force of the pulse does not demonstrate the elasticity of blood vessel walls or reflect the blood volume in the arteries during diastole. Therefore, choices B, C, and D are incorrect.
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