NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. When checking for proper blood pressure cuff size, which guideline is correct?
- A. The standard cuff size is appropriate for all sizes.
- B. The length of the rubber bladder should equal 80% of the arm circumference.
- C. The width of the rubber bladder should equal 80% of the arm circumference.
- D. The width of the rubber bladder should equal 40% of the arm circumference.
Correct answer: D
Rationale: When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect. Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.
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. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?
- A. Client will be able to turn self by day 3
- B. Skin will remain intact and without redness during hospital stay
- C. Client will state pain relieved within 30 minutes after medication
- D. Pressure will be prevented by repositioning client every 2 hours
Correct answer: B
Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.
4. Which statement best describes evidence-based practice?
- A. Reading and analyzing research reports to determine their implementation in nursing practice
- B. Collecting data to evaluate the efficiency of nursing practice in delivering quality care
- C. Monitoring unit practices to ensure adherence to Joint Commission standards
- D. Using the most effective, current, and applicable information to guide nursing care for the best outcomes
Correct answer: D
Rationale: Evidence-based practice involves utilizing the most effective, current, and relevant information to inform nursing care decisions for optimal client outcomes. While research reports and data collection are important components of evidence-based practice, the essence lies in integrating all available information to determine the best course of action. Monitoring compliance with standards, as described in choices A and C, is essential for quality assurance but does not capture the comprehensive nature of evidence-based practice.
5. During the general survey, what action is a component of the assessment?
- A. Observing the patient's body stature and nutritional status
- B. Interpreting the subjective information reported by the patient
- C. Measuring the patient's temperature, pulse, respirations, and blood pressure
- D. Observing specific body systems during the physical assessment
Correct answer: A
Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.
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