NCLEX-RN
Exam Cram NCLEX RN Practice Questions Questions
Question 1 of 5
A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?
Correct Answer: A
Rationale: To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.
Question 2 of 5
The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?
Correct Answer: C
Rationale: When measuring blood pressure, it's important to account for the possibility of an auscultatory gap, which occurs in about 5% of individuals, particularly those with hypertension due to a noncompliant arterial system. To detect an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears. This ensures an accurate measurement of blood pressure by overcoming the potential gap in sounds. Choice A is correct as it follows this guideline. Choices B and C are incorrect because inflating the cuff to 200 mm Hg or above the patient's pulse rate does not address the specific issue of an auscultatory gap. Choice D is incorrect as it focuses on the patient's previous readings rather than the current measurement technique needed to detect an auscultatory gap.
Question 3 of 5
The healthcare professional has collected the following information on a patient: palpated blood pressure"?180 mm Hg; auscultated blood pressure"?170/100 mm Hg; apical pulse"?60 beats per minute; radial pulse"?70 beats per minute. What is the patient's pulse pressure?
Correct Answer: B
Rationale: Pulse pressure is the numerical difference between the systolic and diastolic blood pressure readings. In this case, the systolic blood pressure is 170 mm Hg, and the diastolic blood pressure is 100 mm Hg. Therefore, the pulse pressure is calculated as 170 - 100 = 70 mm Hg. Pulse pressure reflects the stroke volume, the amount of blood ejected from the heart with each beat. Choices A, C, and D are incorrect because they do not accurately represent the difference between the systolic and diastolic blood pressure readings provided.
Question 4 of 5
When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
Correct Answer: A
Rationale: When auscultating blood pressure, it is crucial to note the points at which Korotkoff sounds change. In adults, the last audible sound indicates the diastolic pressure. In this case, the Korotkoff sounds muffle at 100 mm Hg and disappear at 92 mm Hg. Therefore, the blood pressure should be recorded as systolic/diastolic, which is 200/92. Choices B, C, and D are incorrect because they do not reflect the correct points where the Korotkoff sounds change during blood pressure measurement.
Question 5 of 5
A patient is seen in the clinic for reports of "fainting episodes that started last week."? How would the nurse proceed with the examination?
Correct Answer: C
Rationale: When a patient reports fainting episodes, it is crucial to assess for orthostatic hypotension. If the nurse suspects volume depletion, the patient has hypertension, is on antihypertensive medications, or has a history of fainting or syncope, blood pressure readings should be taken in three positions: lying, sitting, and standing. This assessment helps detect orthostatic hypotension, which can provide valuable information about the patient's condition. Taking blood pressure readings in multiple positions allows for a comprehensive evaluation of possible postural changes in blood pressure. Choices A, B, and D are incorrect because they do not cover the necessary positions to assess for orthostatic hypotension effectively.