NCLEX-RN
NCLEX RN Exam Review Answers
1. The healthcare professional needs to validate which of the following statements pertaining to an assigned client?
- A. The client has a hard, raised, red lesion on his right hand.
- B. A weight of 185 lbs. is recorded in the chart.
- C. The client reported an infected toe.
- D. The client's blood pressure is 124/70.
Correct answer: C
Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3, and 4. The weight, blood pressure, and physical appearance of a lesion can be objectively verified. However, option C, the client reporting an infected toe, requires the nurse to directly assess the client's toe to confirm the statement. This choice involves subjective data that needs to be validated through direct observation, making it the correct answer. Options A, B, and D provide data that can be measured objectively and verified without the need for further assessment.
2. A systemic sign of infection is ______________.
- A. swelling
- B. redness
- C. heat
- D. a lack of appetite
Correct answer: D
Rationale: The correct answer is 'a lack of appetite.' When a person experiences a systemic infection, they may exhibit signs that affect the entire body. A lack of appetite is a common systemic sign of infection, along with other symptoms like rapid pulse, fever, and an elevated white blood cell count. Swelling, redness, and heat are more indicative of localized inflammation or infection, rather than systemic involvement.
3. Mrs. O is seen for follow-up after an episode of acute pancreatitis. Her physician orders a serum amylase level and the result is 200 U/L. Which of the following is a potential cause of this result?
- A. The client is pregnant
- B. The client has hypertension
- C. The client is in renal failure
- D. The client has pancreatitis
Correct answer: D
Rationale: An elevated serum amylase level after pancreatitis may indicate another attack of the condition. It is common to order serum amylase as part of routine follow-up after pancreatitis. Elevated levels can also be seen in related gastrointestinal conditions like cholecystitis or an intestinal blockage. Therefore, in this case, the most likely cause of the elevated serum amylase level is a recurrence or ongoing pancreatitis. The other options, including pregnancy, hypertension, and renal failure, are not typically associated with an elevated serum amylase level in the context of follow-up after acute pancreatitis.
4. What is the purpose of performing quality control?
- A. Create a paper trail to show that the laboratory is compliant with OSHA standards for quality control.
- B. Improve the odds that the results reported for any given test are as accurate and reliable as possible.
- C. Be required by law to be part of a quality assurance program.
- D. All of the above
Correct answer: B
Rationale: The primary purpose of performing quality control is to enhance the accuracy and reliability of test results. Quality controls are crucial for ensuring the reliability of each analyte tested. While quality control is not mandated by specific laws, accrediting bodies often require it to maintain accreditation. Creating a paper trail and legal requirements are not the primary objectives of quality control, making choices A and C incorrect. Therefore, the correct answer is to improve the accuracy and reliability of reported test results.
5. What is the expected date of delivery for your pregnant client when her last menstrual period was on 10/20/2016
- A. 7/7/2017
- B. 8/7/2017
- C. 6/7/2017
- D. 8/1/2017
Correct answer: A
Rationale: The expected date of delivery is calculated using Nagle's rule which is: The first day of last menstrual period - 3 months + 7 days = the estimated date of delivery
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