you have been asked to record the amount of food that the person has eaten during each meal what kinds of words or numbers would you use to record thi

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

A. A little, a moderate amount, or all of the meal
B. 50 cc, 100 cc, or 500 cc of the meal
C. 25%, 50%, or 100% of the meal
D. Either A or C

Correct answer: C

Rationale: Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate. Choices A and B are incorrect. Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation. Choice B's use of cc is more appropriate for measuring fluids, not solid foods. Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.

2. A patient's blood pressure is 118/82 mm Hg. The patient asks the nurse, "What do the numbers mean?"? Which is the best reply by the nurse?

A. "The numbers are within the normal range and are nothing to worry about."?
B. "The bottom number is the diastolic pressure and reflects the pressure in the arteries when the heart relaxes."?
C. "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts."?
D. "The concept of blood pressure can be complex. The primary thing to be concerned about is the top number, or the systolic blood pressure."?

Correct answer: C

Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume. Both the systolic and diastolic blood pressure are important. Choice A is incorrect as providing a vague reassurance does not address the patient's query. Choice B is incorrect as it inaccurately describes the diastolic pressure as reflecting stroke volume, which is incorrect. Choice D is incorrect as it oversimplifies the explanation, focusing solely on the top number without providing a complete understanding of blood pressure.

3. Over a patient's lifespan, how does the pulse rate change?

A. starts out fast and decreases as the patient ages.
B. starts out slower and increases as the patient ages.
C. varies from slow to fast throughout the lifespan.
D. stays consistent from birth to death.

Correct answer: A

Rationale: The correct answer is that the pulse rate starts out fast and decreases as the patient ages. In infants, the normal pulse rate is around 140 beats per minute, which then falls to an average of 80 beats per minute in adults. As individuals age, their pulse rate tends to decrease due to changes in cardiovascular function. Choice B is incorrect as the pulse rate typically decreases with age, rather than increases. Choice C is incorrect as there is a general trend of decreasing pulse rate as individuals age, rather than a continuous variation. Choice D is incorrect as the pulse rate does change over a patient's lifespan, starting fast in infants and decreasing as they age.

4. A client's intake and output are being calculated by a nurse. During the last shift, the client consumed � cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client also urinated 250 cc and had 2 bowel movements. What is this client's intake and output for this shift?

A. 420 cc intake, 250 cc output
B. 300 cc intake, 250 cc output
C. 550 cc intake, 550 cc output
D. 300 cc intake, 550 cc output

Correct answer: A

Rationale: The correct answer is 420 cc intake and 250 cc output for this shift. To calculate the intake, � cup of gelatin (approximately 120 cc) and 300 cc of water should be added together, resulting in 420 cc. Food intake like the chicken breast and green beans is not converted to cc's but may be documented for hospital protocol. Output includes urine (250 cc in this case) and other forms like vomit, diarrhea, or gastric suction. Bowel movements are not converted to cc's, but the nurse may need to document the number of stools passed. Choices B, C, and D are incorrect because they do not accurately reflect the intake and output calculations based on the information provided.

5. 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.