NCLEX-RN
NCLEX RN Simulated Exam Test Bank Questions
Extract:
Question 1 of 5
What are Korotkoff sounds?
Correct Answer: B
Rationale: Korotkoff sounds are the sounds that occur when blood flows in an artery that has been temporarily compressed during a blood pressure measurement. These sounds result from the vibration of blood against the artery walls as the pressure cuff is released. There are five distinct phases of Korotkoff sounds, which healthcare providers are trained to identify during blood pressure assessment. The correct answer, choice B, accurately describes the nature of Korotkoff sounds and how they are generated.
Choices A, C, and D are incorrect because Korotkoff sounds are not specific to diastole, not limited to skilled cardiologists, and categorized into five phases, not six.
Question 2 of 5
Which of the following bony landmarks is described as a large, blunt, irregularly shaped process found on the lateral aspect of the proximal femur?
Correct Answer: D
Rationale: The correct answer is D: Trochanter. The Greater Trochanter is located on the lateral aspect of the proximal femur and is a large, blunt, irregularly shaped bony process. It serves as an important attachment site for many muscles of the legs, providing leverage and movement.
Choice A, Tubercle, is a small rounded projection, usually for the attachment of a ligament or tendon.
Choice B, Tuberosity, is a large rounded projection, also typically for muscle attachment.
Choice C, Condyle, refers to a rounded articular surface at the end of a bone, usually involved in joints.
Question 3 of 5
A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
Correct Answer: B
Rationale: The priority nursing diagnosis in this scenario is 'Risk for suicide.' When a patient presents with major depression, significant weight loss, suicidal ideation, and lack of symptom improvement despite medication, the immediate concern is to address the risk of suicide. 'Risk for suicide' takes precedence as it involves a direct threat to the patient's life. 'Imbalanced nutrition: Less than body requirements' may be a concern but does not take priority over the risk of suicide. 'Chronic low self-esteem' and 'Hopelessness' are relevant issues in depression but are not as urgent as addressing the immediate risk of suicidal behavior.
Question 4 of 5
What is the flap of tissue that covers the trachea upon swallowing called?
Correct Answer: C
Rationale: The correct answer is C: Epiglottis. The epiglottis is a flap of tissue that covers the trachea when swallowing to prevent food or liquid from entering the airway.
Choice A, Epidermis, is the outer layer of the skin and is not related to the trachea.
Choice B, Endocardium, is the inner lining of the heart chambers and is also unrelated to the trachea.
Choice D, Epistaxis, refers to a nosebleed and is not the correct term for the tissue covering the trachea.
Question 5 of 5
An adult's blood pressure reads 40/20. You place the patient in a Trendelenberg position before rechecking the blood pressure. What actions will you take to position the patient correctly?
Correct Answer: A
Rationale: In a Trendelenberg position, used for low blood pressure, the correct action is to lower the head of the bed and raise the foot of the bed. This positioning facilitates the return of blood to the heart and helps increase blood pressure. Option B, raising the head of the bed to 60 to 75 degrees, is incorrect as it is not the Trendelenberg position. Option C, raising the head of the bed to 75 to 90 degrees, is incorrect as it does not align with the Trendelenberg position. Option D, raising the siderails and placing the bed in the high position, is incorrect as it does not address the specific positioning required for the Trendelenberg position.