NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. When performing an EKG, the patient starts to laugh out of feelings of anxiety. What would you expect the EKG to show? (Choose the BEST answer.)
- A. Increased pulse rate, normal EKG
- B. Decreased pulse rate, abnormal EKG
- C. Tachycardia, poor EKG graph
- D. Bradycardia, poor EKG graph
Correct answer: C
Rationale: When a patient laughs due to anxiety during an EKG, it is likely to cause tachycardia, which is a rapid heart rate. This increased heart rate can lead to poor EKG graph quality as the electrical signals from large moving muscles can interfere with data collection from the chest leads. Therefore, in this scenario, the EKG is expected to show tachycardia with poor graph quality. Choices A, B, and D are incorrect because a patient laughing out of anxiety is more likely to result in an increased pulse rate (tachycardia) rather than a decreased pulse rate (bradycardia) or a normal EKG.
2. 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.
3. Which vacutainer tubes should be used when a requisition calls for blood to be drawn for an H&H and glucose test?
- A. One light blue, one red
- B. Two lavenders
- C. One lavender, one grey
- D. One green, one red
Correct answer: D
Rationale: The correct answer is 'One green, one red.' An H&H test involves hemoglobin and hematocrit, which are components of a complete blood count and are typically drawn in a lavender tube. On the other hand, blood for glucose testing is collected in grey tubes. Therefore, when drawing blood for both an H&H and glucose test, one green tube for glucose and one red tube for H&H should be used. The other choices are incorrect because light blue tubes are used for coagulation studies, lavender tubes are for complete blood counts, and green tubes are for chemistry tests like glucose, while grey tubes are specifically for glucose testing.
4. During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?
- A. 40-year-old with chronic pancreatitis who has gnawing abdominal pain
- B. 58-year-old who has compensated cirrhosis and is complaining of anorexia
- C. 55-year-old with cirrhosis and ascites who has an oral temperature of 102�F (38.8�C)
- D. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain
Correct answer: C
Rationale: When prioritizing patient assessments, the nurse should address the patient with cirrhosis and ascites who has an elevated oral temperature of 102�F (38.8�C) first. This presentation suggests a potential infection, which is critical to address promptly in a patient with liver disease. An infection in a patient with cirrhosis can quickly progress to severe complications. The other options, such as chronic pancreatitis with abdominal pain, compensated cirrhosis with anorexia, and post-laparoscopic cholecystectomy with shoulder pain, do not indicate an immediate life-threatening situation requiring urgent assessment compared to a possible infection in a patient with cirrhosis and ascites.
5. When a sequence of repeated weights is necessary, the healthcare provider should aim to weigh the patient at the same time of day and with consistent clothing. Using a standardized balance or electronic standing scale is recommended for accurate measurements. The patient should remove shoes and heavy outer clothing. It is not required for the patient to always be weighed in undergarments. What is the most appropriate indicator of the patient's overall well-being?
- A. General health
- B. Genetic makeup
- C. Nutritional status
- D. Activity and exercise patterns
Correct answer: A
Rationale: Weight measurements are essential to assess general health, particularly in monitoring growth patterns. Height and weight recordings are crucial indicators of overall well-being, reflecting the individual's health status. Genetic makeup does not change with weight fluctuations, making it an inappropriate indicator. Nutritional status and activity levels can influence weight but are not as comprehensive as general health in reflecting overall well-being.
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