NCLEX-RN
NCLEX RN Exam Preview Answers
1. Which of the following descriptions best describes the function of the thyroid gland?
- A. The thyroid gland converts glucose into glycogen
- B. The thyroid gland secretes cortisol during times of stress
- C. The thyroid gland regulates body metabolism
- D. The thyroid gland affects skin pigmentation
Correct answer: C
Rationale: The thyroid gland is responsible for secreting thyroxine (T4) and triiodothyronine (T3), which work to regulate the metabolism of the body's cells. The primary function of the thyroid gland is to control the body's metabolic rate, affecting processes such as heart rate, temperature regulation, and energy levels. Choices A, B, and D are incorrect because the thyroid gland is not involved in converting glucose into glycogen, secreting cortisol, or affecting skin pigmentation. Instead, the primary role of the thyroid gland is to regulate the metabolism and energy balance in the body.
2. Which of the following lists the recommended sequence for removing soiled personal protective equipment when preparing to leave a patient's room?
- A. Gown, goggles, mask, gloves, and exit the room.
- B. Gloves, wash hands, remove gown, mask, and goggles.
- C. Gloves, goggles, gown, mask, and wash hands.
- D. Gloves, goggles, gown, mask, and wash hands.
Correct answer: D
Rationale: The correct sequence for removing soiled personal protective equipment is crucial to prevent contamination. Gloves should always be removed first as they are most likely to be contaminated. Following the removal of gloves, goggles, gown, mask, and finally washing hands is recommended. Choice A is incorrect as gloves should be removed first. Choice B is incorrect as the sequence is not in the recommended order. Choice D is incorrect as gloves should be removed before goggles.
3. What is a common error when taking a pulse?
- A. Placing the index finger on the radial artery located on the thumb side of a patient's wrist.
- B. Noting a pulse as 'weak' when the pulsation disappears upon adding pressure.
- C. Counting the pulse for 15 seconds and multiplying the number by four.
- D. None of the above will cause errors.
Correct answer: C
Rationale: The correct answer is counting the pulse for 15 seconds and multiplying the number by four. To accurately assess a patient's heart rate or pulse, it is crucial to count the pulse for a full minute. Counting for only 15 seconds and then multiplying by four may result in an inaccurate heart rate calculation. This approach could miss arrhythmias or intermittent pulsations that could be vital indicators of the patient's condition. Placing the index finger on the radial artery, which is located on the thumb side of the patient's wrist, is the correct technique for taking a pulse. Noting a pulse as 'weak' when the pulsation disappears upon adding pressure is a valid observation and not an error in itself. Therefore, the most common error in this scenario is incorrectly calculating the pulse rate by multiplying a 15-second count by four.
4. The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature"?36�C; pulse"?48 beats per minute; respirations"?14 breaths per minute; blood pressure"?104/68 mm Hg. Which statement is true concerning these results?
- A. The patient is experiencing bradycardia.
- B. These are normal vital signs for a healthy, athletic adult.
- C. The patient's pulse rate is not normal"?no action is required.
- D. The patient's next clinic visit should occur as scheduled.
Correct answer: B
Rationale: The correct answer is, 'These are normal vital signs for a healthy, athletic adult.' A pulse rate of 48 beats per minute is considered bradycardia in adults, but it is not a concern in well-trained athletes like marathon runners. Bradycardia is a normal physiological response to aerobic conditioning. Tachycardia, on the other hand, is defined as a pulse rate above 100 beats per minute, which is not the case here. The low pulse rate in this scenario is a reflection of the athlete's cardiovascular fitness. Therefore, there is no need to notify the physician or schedule a follow-up visit based on these findings.
5. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?
- A. 240 cc
- B. 120 cc
- C. 8 cc
- D. 0 cc because Italian ice is not a fluid
Correct answer: A
Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.
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