NCLEX-RN
NCLEX RN Simulated Exam Test Bank Questions
Extract:
Question 1 of 5
A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?
Correct Answer: A
Rationale: Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension.
Choice A, 142/92, falls within this range, making it the correct answer.
Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension.
Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.
Question 2 of 5
You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?
Correct Answer: C
Rationale: Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate.
Choices A and B are incorrect.
Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation.
Choice B's use of cc is more appropriate for measuring fluids, not solid foods.
Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.
Question 3 of 5
A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up."? Which nursing intervention should have the highest priority?
Correct Answer: D
Rationale: The highest priority nursing intervention in this scenario should be suicide precautions. The patient's statement indicates suicidal ideation, which poses an immediate risk to their safety. By implementing suicide precautions, the nurse can ensure constant monitoring and intervention to prevent any self-harm. While addressing self-esteem, anxiety, and sleep issues are essential, ensuring the patient's safety by prioritizing suicide precautions is crucial. Self-esteem-building activities, anxiety self-control measures, and sleep enhancement activities are important interventions but should follow the immediate concern of preventing harm from suicidal thoughts.
Question 4 of 5
A physician's order instructs a nurse to take a temperature at the axilla. Where would the nurse place the thermometer?
Correct Answer: A
Rationale: When a physician's order specifies taking a temperature at the axilla, the nurse should place the thermometer in the armpit. The axilla is the anatomical area of the armpit located under the arms, proximal to the trunk. Placing the thermometer in the rectum (
Choice
A) is used for rectal temperature measurements, in the mouth (
Choice
B) for oral temperature measurements, and on the temples (
Choice
C) is not a common site for temperature assessment.
Therefore, the correct placement based on the given instruction is in the armpit.
Question 5 of 5
What is the anatomic structure located in the middle of the heart that separates the right and left ventricles?
Correct Answer: A
Rationale: The correct answer is the septum. The septum is a structure located in the middle of the heart that separates the right and left ventricles. It plays a crucial role in maintaining the separation between the two ventricles to ensure efficient blood flow. The other choices, 'Sputum' and 'Separator,' are incorrect as they do not refer to the anatomic structure in the heart that serves this specific function. 'Sputum' is a term used to describe phlegm or mucus, not an anatomical structure, and 'Separator' is a generic term that does not specifically identify the cardiac structure mentioned in the question.