NCLEX-RN
NCLEX RN Exam Prep
1. Which of the following is an example of emotional neglect?
- A. A slap to the person's hand
- B. Threatening the person
- C. Ignoring and isolating a person
- D. Leaving a patient soiled for hours
Correct answer: C
Rationale: The correct answer is ignoring and isolating a person. Emotional neglect involves failing to meet the emotional needs of individuals, which can include ignoring their feelings and isolating them. Choices A, B, and D involve physical aggression, verbal threats, and neglect of physical care, respectively. These actions may be forms of abuse or neglect, but they do not specifically relate to emotional neglect as described in the question.
2. Which of the following may represent an upper airway obstruction?
- A. Retractions
- B. Elongated expiratory phase
- C. Stridor
- D. Expiratory wheezing
Correct answer: C
Rationale: Stridor is the sound produced by turbulent airflow through a partially obstructed upper airway. It is a classic sign of upper airway obstruction. While an elongated expiratory phase may indicate lower airway obstruction, stridor specifically points to an upper airway issue. Retractions are also often seen in upper airway obstruction due to the increased effort of breathing. Expiratory wheezing, on the other hand, is more indicative of lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD).
3. You are ready to give your resident a complete bed bath. The temperature of this bath water should be which of the following?
- A. Cooler than a tub bath.
- B. Hotter than a tub bath.
- C. About 106 degrees.
- D. Over 120 degrees.
Correct answer: C
Rationale: The correct temperature for a bed bath water should be about 106 degrees. This temperature is considered safe and comfortable for residents. Using a bath thermometer is essential to ensure the water is not too hot, as hot water can cause burns. On the other hand, water that is too cool can lead to discomfort, shivering, and chilling. Options A, B, and D are incorrect because cooler water may cause discomfort and shivering, hotter water can lead to burns, and water over 120 degrees is considered too hot and risky for a resident's skin.
4. When assessing a pulse, what should be noted?
- A. Rate
- B. Rate and quality
- C. Rate, quality, and fullness
- D. Rate, quality, fullness, and regularity
Correct answer: C
Rationale: When assessing a pulse, it is important to note the rate (number of beats per minute), quality (regular or irregular), and fullness (thread and weak or full and bounding). These aspects provide crucial information about the patient's cardiovascular status. Regularity, as mentioned in option D, is not typically assessed during a pulse check and is not necessary for routine pulse assessment. Choice A is too limited as it overlooks important aspects beyond just the rate. Choice B improves by adding quality but still lacks the fullness aspect. Choice C is the most comprehensive and accurate as it includes all three essential aspects for a thorough pulse assessment.
5.
- 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.
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