NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?
Correct Answer: C
Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. During the implementation phase, the nurse puts the care plan into action, which includes coordinating with other healthcare team members like the physical therapy department. Assessment involves data gathering, planning involves goal setting, and evaluation involves determining the attainment of client goals.
Question 2 of 5
During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?
Correct Answer: D
Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option
A), reviewing the client's medical record history (Option
B), and explaining the purpose of administered medications to the client (Option
C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.
Question 3 of 5
A patient has been told to monitor her LH levels. Which of the following potential conditions might the patient be suffering from?
Correct Answer: D
Rationale: Luteinizing hormone (LH) is released by the pituitary gland to stimulate ovulation. One of the common reasons for monitoring LH levels is infertility. In women with infertility, LH levels are monitored to time intercourse accurately to maximize the chances of conception. Menorrhagia (choice
A) is characterized by heavy menstrual bleeding and is not directly related to LH levels. Grave's Disease (choice
B) is an autoimmune disorder affecting the thyroid gland and is not typically monitored by LH levels. Menopause (choice
C) is a natural process marking the end of a woman's reproductive years and is not a condition where LH monitoring for infertility is common.
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
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.