NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
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?
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.
Question 2 of 5
During which part of the client interview would it be best for the nurse to ask, 'What's the weather forecast for today?'
Correct Answer: A
Rationale: Asking about the weather initiates the social or introductory phase of the interview, allowing the nurse to establish rapport with the client at the beginning. This question can help assess the client's mental status and set a friendly tone. In the body phase, the client responds to the nurse's inquiries, while during the closing phase, either the nurse or the client concludes the interview.
Therefore, the best time to ask about the weather forecast is during the introduction phase to facilitate a positive start to the interaction.
Question 3 of 5
After performing the appropriate client assessment, which of the following inferences would the nurse make?
Correct Answer: A
Rationale: An inference is the nurse's judgment or interpretation of cues gathered during an assessment. In this scenario, identifying a client as hypotensive would be an inference based on blood pressure readings that indicate lower than normal values. Respiratory rate and oxygen saturation levels (choices B and
C) are important cues that provide additional data but do not directly point to a specific conclusion like hypotension. The client expressing anxiety about blood work (choice
D) is relevant information but relates more to their emotional state rather than a physiological assessment finding.
Question 4 of 5
To properly read a meniscus,
Correct Answer: A
Rationale:
To properly read a meniscus, it is essential to hold the measuring device at eye level to avoid parallax error. Reading the bottom of the curve of the liquid level is correct because the meniscus is the concave or convex curve at the liquid's surface.
Choice B is incorrect because reading the top of the curve where the liquid adheres to the walls of the container can lead to inaccurate measurements.
Choices C and D are incorrect as they suggest holding the device at table level, which can introduce parallax error and result in an incorrect reading.
Question 5 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.