NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. When assessing a pulse, what should be noted?
- A. Rate
- B. Rate and quality
- C. Rate, quality, and fullness
- D. Rate, quality, fullness, and regularity
Correct answer: C
Rationale: When assessing a pulse, it is important to note the rate (number of beats per minute), quality (regular or irregular), and fullness (thread and weak or full and bounding). These aspects provide crucial information about the patient's cardiovascular status. Regularity, as mentioned in option D, is not typically assessed during a pulse check and is not necessary for routine pulse assessment. Choice A is too limited as it overlooks important aspects beyond just the rate. Choice B improves by adding quality but still lacks the fullness aspect. Choice C is the most comprehensive and accurate as it includes all three essential aspects for a thorough pulse assessment.
2. A physician asks you to place the patient with his dorsal side facing the exam table. Which of the following accurately describes how the patient is positioned?
- A. The patient is lying prone.
- B. The patient is lying supine.
- C. The patient is lying in the recovery position.
- D. The patient is lying on his stomach.
Correct answer: B
Rationale: When the physician asks for the patient to be placed with their dorsal side facing the exam table, it means the patient should be lying on their back. This position is known as the supine position, where the patient's back is on the table, facing up towards the ceiling. Choice A, 'The patient is lying prone,' is incorrect as the prone position is when the patient is lying face down. Choice C, 'The patient is lying in the recovery position,' is incorrect as the recovery position is a lateral position typically used in first aid. Choice D, 'The patient is lying on his stomach,' is incorrect as it describes the prone position, not the supine position as required in this scenario.
3. Which practice will help reduce the risk of a needlestick injury?
- A. Expose the end of the needle only when ready to enter the room for the procedure
- B. Never recap a needle after use
- C. Keep a sharps container nearby where it can be easily accessed
- D. Exchange needles from a central area rather than passing them between workers
Correct answer: C
Rationale: To reduce the risk of a needlestick injury, it is essential to keep a sharps container nearby where it can be easily accessed. This practice ensures quick and safe disposal of needles after use, minimizing the chances of accidental needlesticks. Recapping needles should be avoided as it increases the risk of injuries. Passing needles between workers should also be avoided to prevent accidental needle pricks during handovers. Therefore, the best practice to prevent needlestick injuries is to maintain a sharps container nearby for safe and immediate disposal of needles.
4. You are taking care of 5 patients today. One of your patients wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care problem must you deal with first?
- A. The water
- B. Help to the bathroom
- C. The chest pain
- D. The crying person
Correct answer: C
Rationale: The chest pain must be addressed immediately as it could indicate a serious condition like a heart attack. Treating chest pain is a top priority in healthcare settings due to the potential life-threatening nature of the symptom. Providing immediate attention to chest pain ensures prompt assessment, diagnosis, and intervention, which are crucial for patient safety and well-being. Addressing the other needs, such as providing water, assisting with bathroom needs, or emotional support, can follow once the urgent issue of chest pain has been managed. While the other patient concerns are important, the critical nature of chest pain requires immediate action to rule out severe cardiac events and provide appropriate care.
5. A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?
- A. Inform the client that he may experience tingling sensations.
- B. Connect the TENS unit before the client goes to bed for the night.
- C. Inform the client that the TENS unit may have pain-reducing effects for 10 to 15 days.
- D. After treatment, inform the client that he may not use a TENS unit again for at least 2 weeks.
Correct answer: A
Rationale: When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.
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