NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. Which of the following is an anthropometric measurement?
- A. Blood pressure
- B. Temperature
- C. Pulse Rate
- D. Weight
Correct answer: D
Rationale: Anthropometric measurements relate to the size, weight, and proportions of the human body. Weight is a key anthropometric measurement as it directly reflects body mass, making it the correct choice. Blood pressure, temperature, and pulse rate are physiological measurements that do not specifically pertain to body size or proportion, hence making them incorrect choices in the context of anthropometric measurements.
2. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?
- A. No, this temperature is within normal limits.
- B. No, this temperature is normally hyperthermic.
- C. Yes, this temperature is highly hyperthermic.
- D. Yes, this temperature is highly hypothermic.
Correct answer: A
Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.
3. Patients have a right to ______________.
- A. only enough information so they can comply with care
- B. ALL of their health-related information
- C. small amounts of information so they do not get nervous
- D. moderate amounts of information unless they are old
Correct answer: B
Rationale: Patients have a legal right to access all of their health-related information. This includes details about their health condition, treatment options, test results, and any other relevant data. Providing patients with all their health-related information empowers them to make informed decisions about their care, promotes transparency in the healthcare process, and respects their autonomy. Choices A, C, and D are incorrect because they restrict the information patients should receive based on assumptions or limitations, which goes against the principle of patient autonomy and their right to access their complete health-related information.
4. A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed but is unable to ambulate without help. What is the most appropriate safety measure?
- A. Restrain the client in bed
- B. Ask a family member to stay with the client
- C. Check the client every 15 minutes
- D. Use a bed exit safety monitoring device
Correct answer: D
Rationale: Option D is the most appropriate safety measure in this scenario. Using a bed exit safety monitoring device allows the client to retain some independence while ensuring that the nursing staff is alerted when assistance is needed. This solution promotes client safety without compromising their autonomy. Option A, restraining the client in bed, can lead to increased agitation, confusion, and a loss of independence. Option B, asking a family member to stay with the client, shifts the responsibility away from the healthcare team. Option C, checking the client every 15 minutes, is not a sufficient safety measure as the client could attempt to get out of bed in the unobserved interval, risking falls and injury.
5. What is the primary purpose of a patient care meeting or conference?
- A. the patient's ability to pay for the costs of their care
- B. how the healthcare team can best meet the patient's needs
- C. the patient's physical status and condition
- D. the patient's psychosocial status and condition
Correct answer: B
Rationale: The primary purpose of a patient care meeting or conference is to determine how the healthcare team can best meet the patient's needs. These meetings involve discussions among healthcare professionals to tailor the care plan to the specific needs and preferences of the patient. Option A is incorrect because financial discussions are generally not the primary focus of patient care meetings. Option C is incorrect as the patient's physical status is usually already known and is not the primary purpose of the meeting. Option D is incorrect as psychosocial aspects, while important, are not the sole focus of the meeting, which is primarily about addressing the patient's overall needs and preferences.
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