when auscultating the blood pressure of a 25 year old patient the nurse notices that the phase i korotkoff sounds begin at 200 mm hg at 100 mm hg the

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?

A. 200/92
B. 200/100
C. 100/200/92
D. 200/100/92

Correct answer: A

Rationale: When auscultating blood pressure, it is crucial to note the points at which Korotkoff sounds change. In adults, the last audible sound indicates the diastolic pressure. In this case, the Korotkoff sounds muffle at 100 mm Hg and disappear at 92 mm Hg. Therefore, the blood pressure should be recorded as systolic/diastolic, which is 200/92. Choices B, C, and D are incorrect because they do not reflect the correct points where the Korotkoff sounds change during blood pressure measurement.

2. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?

A. Collaborating with the client to establish healthcare goals
B. Reviewing the client's medical record history
C. Explaining the purpose of administered medications to the client
D. Rapidly resetting priorities for client care based on changes in the client's condition

Correct answer: D

Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.

3. Which of the following is a fat-soluble vitamin?

A. Vitamin C
B. Vitamin D
C. Vitamin B-6
D. Riboflavin

Correct answer: B

Rationale: The correct answer is Vitamin D. Fat-soluble vitamins are those that can be stored in the body, allowing excess amounts to be stored for later use. While this storage ability can help prevent deficiencies, it also poses a risk of toxicity. The fat-soluble vitamins are A, E, D, and K. Choice A, Vitamin C, is water-soluble, not fat-soluble. Choice C, Vitamin B-6, and Choice D, Riboflavin, are also water-soluble vitamins and not fat-soluble.

4. Which of the following actions can help prevent a fire in the area where a healthcare professional works?

A. Using an adaptor when plugging in client equipment
B. Marking equipment that is not working properly and using it carefully until it can be inspected by maintenance
C. Notifying visitors or posting signs that indicate oxygen is in use in certain areas
D. Keeping extra equipment stored in one area with other supplies and materials

Correct answer: C

Rationale: The correct action to help prevent a fire in a healthcare setting is to notify visitors or post signs indicating that oxygen is in use in certain areas. Oxygen is a combustible material, and awareness of its presence is crucial to prevent fire hazards. By informing all individuals in the facility about the use of oxygen through clear signs or notifications, the risk of improper use and potential fire accidents can be minimized. Choice A is incorrect because using an adaptor when plugging in client equipment is not directly related to fire prevention. Choice B is also incorrect as marking faulty equipment and using it until inspection does not directly address fire prevention. Choice D is not a recommended action for fire prevention; storing extra equipment with supplies does not address the specific fire risk associated with oxygen use.

5. A patient suffering from hyperglycemia would be experiencing:

A. Low blood sugar
B. High blood sugar
C. Normal blood sugar
D. None of the above

Correct answer: B

Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.