NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:
Correct Answer: B
Rationale: A pneumothorax causes collapsed lung tissue, leading to decreased breath sounds, and rib fractures cause chest pain with movement.
Question 2 of 5
A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse's anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client's behavior?
Correct Answer: A
Rationale: The nurse appropriately states how he or she feels when the client speaks in a condescending manner. This statement indicates that the client has control over the nurse. No one makes another person angry; each individual has a choice. 'Why' questions usually put a person on the defensive. In addition, the client cannot 'make' the nurse angry. The client does not have that control. Again, a 'why' statement places the client on the defensive.
Question 3 of 5
A client with a head injury has an intracranial pressure (ICP) monitor in place. Cerebral perfusion pressure calculations are ordered. If the client's ICP is 22 and the mean pressure reading is 70, what is the client's cerebral perfusion pressure?
Correct Answer: 58
Rationale: Cerebral perfusion pressure (CPP) is calculated as CPP = MAP - ICP. Given MAP = 70 mmHg and ICP = 22 mmHg, CPP = 70 - 22 = 48 mmHg. Thus, the correct answer is 48.
Question 4 of 5
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
Correct Answer: D
Rationale: The wound is healing properly and is filled with red granulated tissue and fragile capillaries.
Question 5 of 5
The well child assessment of a one-year-old reveals orange discoloration of the nasolabial folds. Based on this finding the nurse should:
Correct Answer: A
Rationale: Orange discoloration of the nasolabial folds may result from excessive dietary beta-carotene (e.g. from carrots or sweet potatoes). Obtaining a diet history is the most appropriate action to identify the cause. The other options are more relevant for jaundice or liver issues.