NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
What would be an appropriate evaluation statement for the nurse to write based on the client's ability to state only two signs of impaired circulation out of three as expected?
Correct Answer: C
Rationale: The appropriate evaluation statement for the nurse to write would be 'Goal not met: Client able to name only two signs of impaired circulation.' In this scenario, the client has only identified two out of the three signs of impaired circulation specified in the desired outcome.
Therefore, the goal has not been fully achieved. It is essential in nursing practice to assess and document client progress accurately. While the client has shown some understanding by correctly identifying numbness and tingling as signs of impaired circulation, the inability to state the third sign indicates an incomplete achievement of the goal. This evaluation helps guide further interventions or educational strategies to help the client meet the desired outcome in the care plan.
Question 2 of 5
The client reports nausea and constipation. Which of the following would be the priority nursing action?
Correct Answer: B
Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (
Choice
A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (
Choice
C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (
Choice
D) should come after the assessment to provide a complete picture of the client's condition.
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
During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?
Correct Answer: B
Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.
Question 5 of 5
Each small square on the EKG paper is:
Correct Answer: D
Rationale: Each small square on an EKG paper represents 0.04 seconds long and 1mm tall. This standardization is essential for accurate measurements. One large square on EKG paper consists of 5 small squares in length and 5 small squares in height, which equals 0.2 seconds long and 5mm tall (0.5 mV).
Choice A is incorrect because while the duration is correct, the height mentioned is not accurate.
Choice B is incorrect as it provides the correct height but the duration is inaccurate.
Choice C is incorrect as the height mentioned is exaggerated, and the duration is correct but the height is not.
Therefore, the correct answer is 0.04 seconds long and 1mm tall.