NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?
Correct Answer: C
Rationale:
To confirm glucosuria, the most appropriate method is to run a Clinitest. Clinitest tablets are specifically designed to detect glucose in urine samples. This test is particularly useful when the urine is discolored, making it challenging to accurately assess the color change.\n
Choice A, using a hand-held glucometer, is not the standard method for confirming glucose in urine; these devices are primarily used for blood glucose monitoring.\n
Choice B, having another Medical Assistant perform a repeat dipstick test, may not provide a more definitive confirmation as dipstick tests can sometimes yield false positives or be less accurate compared to other methods like the Clinitest.\n
Choice D, running an Acetest, is used to detect ketones in the urine, not glucose. Ketones are typically associated with conditions like diabetic ketoacidosis, which is different from glucosuria.
Question 2 of 5
Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.
Correct Answer: B
Rationale: Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.
Question 3 of 5
During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?
Correct Answer: D
Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.
Question 4 of 5
A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?
Correct Answer: D
Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.
Question 5 of 5
Why should direct care providers avoid glued-on artificial nails?
Correct Answer: C
Rationale: Direct care providers, including nurses, should avoid glued-on artificial nails because studies have shown that artificial nails, especially when cracked, broken, or split, create crevices where microorganisms can thrive and multiply. This can lead to an increased risk of transmitting infections to patients.
Therefore, the primary reason for avoiding glued-on artificial nails is their potential to harbor harmful microorganisms, making option C the correct choice. Options A, B, and D are incorrect because while they may present some issues, the primary concern is the risk of microbial contamination associated with artificial nails.