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. The nurse is assessing an 80-year-old male patient. Which assessment finding would be considered normal?
- A. Decrease in body weight from his younger years
- B. Decrease in deposits of fat in the cheeks and forearms
- C. Presence of kyphosis and flexion in bilateral knees and hips
- D. Change in overall body proportion, including a longer trunk and shorter extremities
Correct answer: C
Rationale: In an 80-year-old male patient, the presence of kyphosis (rounded upper back) and flexion in bilateral knees and hips are considered normal age-related changes. These postural changes are commonly seen in older adults due to structural changes in the spine and joints. Option A is incorrect as aging individuals typically experience a decrease in body weight, not an increase. Option B is also incorrect as there is usually a decrease in subcutaneous fat from the face and periphery, rather than an increase in fat deposits in specific areas. Option D is incorrect because the change in overall body proportion with aging usually involves a shorter trunk and relatively longer extremities, not the other way around. This is because long bones do not shorten with age, leading to this characteristic change in body proportions.
3. A 60-year-old patient has been treated for pneumonia for the past 6 weeks. The patient is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. Which is an appropriate rationale for this patient's weight loss?
- A. Chronic diseases such as hypertension do not usually cause weight loss.
- B. Weight loss is more likely due to underlying medical conditions than unhealthy eating habits.
- C. Unexplained weight loss often accompanies short-term illnesses.
- D. Weight loss is not typically caused by mental health dysfunctions.
Correct answer: C
Rationale: Unexplained weight loss in a patient with pneumonia could indicate an underlying short-term illness or a chronic condition like endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Hypertension is not commonly associated with weight loss; it usually leads to weight gain due to fluid retention. Unhealthy eating habits are less likely to explain significant unexplained weight loss over a short period. Mental health dysfunctions can affect appetite but are not typically primary causes of significant unexplained weight loss.
4. A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?
- A. 142/92
- B. 118/72
- C. 120/80
- D. 138/88
Correct answer: A
Rationale: Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension. Choice A, 142/92, falls within this range, making it the correct answer. Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension. Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.
5. 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.
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