NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?
- A. "I can always trust my family."?
- B. "It seems like I always have bad luck."?
- C. "You never know who will turn against you."?
- D. "I hear evil voices that tell me to do bad things."?
Correct answer: D
Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis. Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.
2. A patient suffering from hyperglycemia would be experiencing:
- A. Low blood sugar
- B. High blood sugar
- C. Normal blood sugar
- D. None of the above
Correct answer: B
Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.
3. When is a physician likely to assess turgor?
- A. When iron deficiency is suspected.
- B. When heart and lung issues are suspected.
- C. When dehydration is suspected.
- D. None of the above.
Correct answer: C
Rationale: Skin turgor is assessed when dehydration is suspected. To evaluate skin turgor, a physician pinches the skin and observes how quickly it returns to its normal position. If the skin stays folded for an extended period, it indicates dehydration. Assessing turgor helps determine a patient's hydration status. Choice A is incorrect because skin turgor is not used to assess iron deficiency. Choice B is incorrect as turgor is not related to heart and lung issues, but rather hydration status. Choice D is incorrect as turgor assessment is relevant when dehydration is suspected.
4. A patient works with a nurse to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action?
- A. Remain silent.
- B. Educate the patient that the outcome is not realistic.
- C. Explore with the patient possible consequences of the outcome.
- D. Formulate an appropriate outcome without the patient's input.
Correct answer: C
Rationale: In this scenario, the nurse should collaborate with the patient rather than impose personal opinions. While the nurse should respect the patient's autonomy, they also have a duty to provide guidance. By exploring possible consequences of the suggested outcome with the patient, the nurse can facilitate a discussion that helps the patient make an informed decision. This approach respects the patient's input while ensuring their well-being. Remaining silent (Choice A) may not address the issue, educating the patient unilaterally (Choice B) may be perceived as dismissive, and formulating an outcome without patient input (Choice D) disregards the patient's autonomy and preferences.
5. What is the flap of tissue that covers the trachea upon swallowing called?
- A. Epidermis
- B. Endocardium
- C. Epiglottis
- D. Epistaxis
Correct answer: C
Rationale: The correct answer is C: Epiglottis. The epiglottis is a flap of tissue that covers the trachea when swallowing to prevent food or liquid from entering the airway. Choice A, Epidermis, is the outer layer of the skin and is not related to the trachea. Choice B, Endocardium, is the inner lining of the heart chambers and is also unrelated to the trachea. Choice D, Epistaxis, refers to a nosebleed and is not the correct term for the tissue covering the trachea.
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