NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 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 2 of 5
The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
Correct Answer: C
Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment.
Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.
Question 3 of 5
Which of the following items of subjective client data would be documented in the medical record by the nurse?
Correct Answer: D
Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition.
Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse.
Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.
Question 4 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 5 of 5
Which of these is a correctly stated outcome goal written by the nurse?
Correct Answer: A
Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option A is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19). Option B lacks specificity in terms of what 'understand how to give insulin' entails, and the timeline is vague ('by discharge'). Option C is not measurable or specific about what 'regain their former state of health' means. Option D does not provide a specific behavior or measurable criteria for 'desired mobility,' and the timeline is the only element that is time-bound.