NCLEX-RN
NCLEX RN Predictor Exam
1. Which of the following descriptors is most appropriate to use when stating the 'problem' part of a nursing diagnosis?
- A. Grimacing
- B. Anxiety
- C. Oxygenation saturation 93%
- D. Output 500 mL in 8 hours
Correct answer: B
Rationale: The problem part of a nursing diagnosis in the context of nursing care plans should focus on the client's response to a life process, event, or stressor. This response is what is used to identify the nursing diagnosis. 'Anxiety' is the most appropriate descriptor for the problem part of a nursing diagnosis as it reflects a psychological response that can be addressed by nursing interventions. 'Grimacing' is a physical manifestation and not the problem itself. 'Oxygenation saturation 93%' and 'Output 500 mL in 8 hours' are data points or cues that a nurse would use to formulate the nursing diagnostic statement, not the actual problem being addressed.
2. A healthcare professional is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?
- A. Cephalic
- B. Median cubital
- C. Basilic
- D. All of the above
Correct answer: D
Rationale: The correct answer is 'All of the above.' All three of these veins - the cephalic, median cubital, and basilic veins - are located in the antecubital space, which is the area in front of the elbow on the arm. The cephalic vein runs along the outer side of the arm, the basilic vein runs along the inner side of the arm, and the median cubital vein is a connecting vein between the cephalic and basilic veins. Therefore, all three veins can be accessed when drawing blood from the antecubital space. Choices A, B, and C are incorrect because each of these veins individually can be found in the antecubital space.
3. Which of the following tests would MOST LIKELY be performed on a patient who is being monitored for coagulation therapy?
- A. PT/INR
- B. CBC
- C. PTT
- D. WBC
Correct answer: A
Rationale: The correct answer is A: PT/INR. Prothrombin times (PT/INR) are commonly used to monitor patients on Coumadin (warfarin) therapy, an anticoagulant that slows the blood's ability to clot. Monitoring PT/INR levels helps ensure the patient is receiving the appropriate dosage of Coumadin. Choice B, CBC (Complete Blood Count), is a general test that provides information on red blood cells, white blood cells, and platelets but is not specific to monitoring coagulation therapy. Choice C, PTT (Partial Thromboplastin Time), is another coagulation test but is not as commonly used for monitoring Coumadin therapy. Choice D, WBC (White Blood Cell count), is unrelated to monitoring coagulation therapy and is used to assess immune system function.
4. When providing mouth care to a patient in a coma, what should you do to provide good and safe mouth care?
- A. keep the head of the bed up to prevent aspiration
- B. brush the teeth and rinse the mouth with a cup of water
- C. use a special foam swab to brush only the tongue
- D. use a special foam swab to brush the tongue and teeth
Correct answer: D
Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice C) or using a foam swab only on the tongue (choice B) may not provide the comprehensive mouth care necessary for patients in a coma.
5. What does the term 'Afferent Nerve' mean?
- A. Carrying an impulse to the brain
- B. Carrying an impulse away from the brain
- C. Carrying impulses to the motor neurons of the appendicular muscles
- D. None of the above
Correct answer: A
Rationale: The correct answer is 'Carrying an impulse to the brain.' Afferent nerves are sensory nerves that carry signals from sensory receptors towards the central nervous system, including the brain. Choice B, 'Carrying an impulse away from the brain,' is incorrect as this describes efferent nerves which carry signals from the central nervous system to muscles and glands. Choice C, 'Carrying impulses to the motor neurons of the appendicular muscles,' is incorrect as it describes a different type of nerve function. Choice D, 'None of the above,' is incorrect as the correct definition of afferent nerve is indeed 'Carrying an impulse to the brain.'
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