NCLEX-RN
NCLEX RN Predictor Exam Questions
Question 1 of 5
A urine pregnancy test:
Correct Answer: A
Rationale: A urine pregnancy test detects HCG in a pregnant woman's urine. Blood levels of HCG are usually higher and register earlier than HCG levels in the urine.
Choice A is correct because urine pregnancy tests may be negative even if a blood pregnancy test is positive due to the differences in HCG levels in blood and urine.
Choice B is incorrect because a urine pregnancy test can be positive throughout pregnancy, not just in the first trimester.
Choice C is incorrect because LH (luteinizing hormone) is not the hormone detected in a pregnancy test; it is HCG (human chorionic gonadotropin).
Choice D is incorrect because not all the statements provided are true.
Question 2 of 5
A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at the time of admission?
Correct Answer: B
Rationale: The most essential measure when admitting a client who had a seizure is to pad the bed with blankets (Option
B). This is crucial to prevent injury in case of another seizure. Placing a padded tongue depressor at the head of the bed (Option
A) is incorrect as current nursing guidelines advise against putting anything in the client's mouth during a seizure. Informing the client about wearing a medical identification tag (Option
C) and teaching the client about seizures (Option
D) are important but are more relevant once the cause of the seizure is known. It's crucial to remember that not all seizures are classified as epilepsy.
Question 3 of 5
A patient's urine specimen tested positive for bilirubin. Which of the following is most true?
Correct Answer: D
Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing.
Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease.
Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels.
Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.
Question 4 of 5
The nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range?
Correct Answer: C
Rationale: Restraints should be removed every 2 hours to prevent complications. Moving the joints through their full range of motion helps prevent muscle shortening and contractures. Massaging the area promotes circulation and reduces the risk of pressure injuries. Removing restraints less frequently could lead to complications like decreased circulation and skin breakdown. Options A, B, and D are incorrect because they do not align with the standard practice of removing restraints every 2 hours to ensure patient safety and well-being.
Question 5 of 5
Which of the following descriptors is most appropriate to use when stating the 'problem' part of a nursing diagnosis?
Correct Answer: B
Rationale: The problem part of a nursing diagnosis in the context of nursing care plans should focus on the client's response to a life process, event, or stressor. This response is what is used to identify the nursing diagnosis. 'Anxiety' is the most appropriate descriptor for the problem part of a nursing diagnosis as it reflects a psychological response that can be addressed by nursing interventions. 'Grimacing' is a physical manifestation and not the problem itself. 'Oxygenation saturation 93%' and 'Output 500 mL in 8 hours' are data points or cues that a nurse would use to formulate the nursing diagnostic statement, not the actual problem being addressed.