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. What term is used to refer to generalized wasting of body tissues and malnutrition?
- A. Entropion
- B. Confabulation
- C. Induration
- D. Cachexia
Correct answer: D
Rationale: Cachexia is the correct term used to describe the generalized wasting of body tissues, ill health, and malnutrition associated with some chronic diseases. It involves a loss of fat tissue to protect the bones and joints. Clients with cachexia are at risk of pressure ulcers and other complications due to malnutrition and poor health. Entropion refers to an eyelid condition, confabulation is a memory disturbance, and induration is the abnormal hardening of a part of the body.
3. To properly read a meniscus,
- A. hold the measuring device at eye level and read the bottom of the curve of the liquid level
- B. hold the measuring device at eye level and read the top of the curve of the liquid level where the liquid adheres to the walls of the container.
- C. hold the measuring device at table level and, looking down into the measuring device, read the bottom of the curve of the liquid level.
- D. hold the measuring device at table level and, looking down into the measuring device, read the top of the curve of the liquid level.
Correct answer: A
Rationale: To properly read a meniscus, it is essential to hold the measuring device at eye level to avoid parallax error. Reading the bottom of the curve of the liquid level is correct because the meniscus is the concave or convex curve at the liquid's surface. Choice B is incorrect because reading the top of the curve where the liquid adheres to the walls of the container can lead to inaccurate measurements. Choices C and D are incorrect as they suggest holding the device at table level, which can introduce parallax error and result in an incorrect reading.
4. When are manual hematocrits done?
- A. to monitor anemia
- B. by using a microhematocrit tube.
- C. to measure the percentage of plasma to cells.
- D. All of the above.
Correct answer: D
Rationale: Manual hematocrits are performed to monitor anemia, which involves measuring the percentage of red blood cells in the blood. The process involves collecting blood in a microhematocrit tube, then centrifuging it to separate the plasma from the cells. By measuring the ratio of plasma to cells, healthcare providers can assess the patient's hematocrit level. Therefore, all the provided options are correct as they collectively describe the purpose and procedure of manual hematocrits.
5. 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.
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