the nurse is performing a general survey of a patient which finding is considered normal

NCLEX-RN

NCLEX RN Predictor Exam

1. During a general survey of a patient, which finding is considered normal?

A. Body mass index (BMI) of 20.
B. When standing, the patient's base is narrow.
C. The patient appears older than their stated age.
D. Arm span (fingertip to fingertip) is greater than the height.

Correct answer: A

Rationale: A body mass index (BMI) of 20 is considered normal as the range for a normal BMI is between 19-24. When standing, a patient's base should be wide for stability and proper weight distribution. An older appearance than the stated age may indicate a history of chronic illness or chronic alcoholism. In a general survey, the patient's arm span (fingertip to fingertip) should approximately equal the patient's height. An arm span greater than the height may suggest Marfan syndrome. Therefore, the correct choice is a normal BMI of 20, which falls within the healthy range. Choices B, C, and D all describe abnormal findings that may indicate underlying health conditions or syndromes.

2. The NFPA diamond has four colors. The blue diamond:

A. indicates hazards to health.
B. designates that it is safe to use water to put out this type of fire.
C. indicates that ice is necessary to treat an injury with this type of chemical.
D. indicates that the chemical may be incinerated upon disposal.

Correct answer: A

Rationale: The National Fire Protection Agency (NFPA) uses a safety diamond to communicate the level of threat posed by a specific chemical. The blue diamond in the NFPA diamond system signifies potential health hazards associated with the use of that chemical. Choice B is incorrect because the blue diamond does not indicate anything about using water to extinguish fires. Choice C is incorrect as the NFPA diamond does not provide information on treating injuries. Choice D is also incorrect as the blue diamond does not suggest incineration upon disposal; it pertains to health hazards.

3. What is the primary purpose of emergency planning?

A. Comply with the laws of the state.
B. Comply with the laws of the U.S.
C. Comply with both state and U.S. laws
D. Maintain safety

Correct answer: D

Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.

4. After performing the appropriate client assessment, which of the following inferences would the nurse make?

A. Client is hypotensive
B. Respiratory rate of 20 breaths per minute
C. Oxygen saturation of 95%
D. Client relays anxiety about blood work

Correct answer: A

Rationale: An inference is the nurse's judgment or interpretation of cues gathered during an assessment. In this scenario, identifying a client as hypotensive would be an inference based on blood pressure readings that indicate lower than normal values. Respiratory rate and oxygen saturation levels (choices B and C) are important cues that provide additional data but do not directly point to a specific conclusion like hypotension. The client expressing anxiety about blood work (choice D) is relevant information but relates more to their emotional state rather than a physiological assessment finding.

5. During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which one of these statements by the nurse is most appropriate?

A. "Your atrial dysrhythmias are under control."?
B. "You have pitting edema and mild varicosities."?
C. "Your pulse is 80 beats per minute, which is within the normal range."?
D. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs in your lungs."?

Correct answer: C

Rationale: During an examination, providing brief educational information to the patient can enhance rapport, as long as the patient can comprehend the terminology. The most appropriate statement from the nurse is "Your pulse is 80 beats per minute, which is within the normal range." This statement conveys a vital sign in a way that is likely understandable to the patient. Choices A, B, and D use terminology that may be unfamiliar or confusing to the patient. Option A mentions 'atrial dysrhythmias,' which might not be clear to the patient. Option B involves terms like 'pitting edema' and 'varicosities,' which could be unfamiliar to the patient. Option D references 'crackles,' 'wheezes,' and 'rubs,' which might not be easily understood by the patient.