NCLEX-RN
NCLEX RN Simulated Exam Test Bank Questions
Extract:
Question 1 of 5
When is a physician likely to assess turgor?
Correct Answer: C
Rationale: Skin turgor is assessed when dehydration is suspected.
To evaluate skin turgor, a physician pinches the skin and observes how quickly it returns to its normal position. If the skin stays folded for an extended period, it indicates dehydration. Assessing turgor helps determine a patient's hydration status.
Choice A is incorrect because skin turgor is not used to assess iron deficiency.
Choice B is incorrect as turgor is not related to heart and lung issues, but rather hydration status.
Choice D is incorrect as turgor assessment is relevant when dehydration is suspected.
Question 2 of 5
A patient's body temperature has varied over the last 24 hours from 97.6 degrees F in the morning to 99 degrees F in the evening. The patient is worried that this change in temperature may indicate the beginning of a fever. Which of the following BEST explains this phenomenon?
Correct Answer: B
Rationale: The patient is experiencing changes related to a diurnal rhythm. Diurnal rhythm is the phenomenon of body temperature fluctuating depending on the time of day. Temperatures taken in the morning are typically lower than those taken throughout the rest of the day.
Choice A is incorrect because a single elevated temperature reading in the evening does not definitively indicate a fever.
Choice C is incorrect as there is no indication of incorrect temperature measurement.
Choice D is incorrect as the temperature changes are not related to monthly hormones but rather to the body's natural daily rhythm.
Question 3 of 5
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse prioritize first on the list to be discharged in order to make a room available for a new admission?
Correct Answer: A
Rationale: The best candidate for discharge during a need for emergency room availability is a stable patient with a chronic condition who is familiar with their care. In this scenario, the middle-aged client in option A, who has been ventilator dependent for over seven years and admitted with bacterial pneumonia five days ago, is most suitable for discharge. This client is likely stable and can continue medication therapy at home, making them the most appropriate choice for discharge at this time.
Choice B should not be the priority for discharge as the young adult with diabetes mellitus Type 2 admitted with antibiotic-induced diarrhea 24 hours ago may need further monitoring and management of their condition.
Choice C, the elderly client with multiple comorbidities and admitted with Stevens-Johnson syndrome on the same day, is not a suitable candidate for immediate discharge as they may require ongoing medical attention and observation.
Choice D, the adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago, should not be discharged first as acute cellulitis may require continued treatment and monitoring, especially in the context of a positive HIV status.
Question 4 of 5
A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
Correct Answer: C
Rationale: When assigning a floated nurse from another unit to a client in the emergency department, the goal is to choose a patient with minimal anticipated immediate complications. In this scenario, the adolescent with terminal cancer who has been on pain medications and presents with pinpoint pupils and a relaxed respiratory rate of 11 is the most stable option. These assessment findings indicate opioid toxicity, which, while serious, has the least risk of immediate complications compared to the other clients.
Choice A involves a middle-aged client experiencing symptoms of possible cardiac issues due to diet pill overdose, which requires urgent intervention.
Choice B presents a young adult with concerning symptoms of potential psychosis or substance withdrawal, requiring immediate attention.
Choice D involves an elderly client who recently used crack, posing a high-risk situation that requires prompt evaluation and intervention.
Therefore, the correct choice is the adolescent with opioid toxicity, as this client has the least immediate risk of complications among the options provided.
Question 5 of 5
Over a patient's lifespan, how does the pulse rate change?
Correct Answer: A
Rationale: The correct answer is that the pulse rate starts out fast and decreases as the patient ages. In infants, the normal pulse rate is around 140 beats per minute, which then falls to an average of 80 beats per minute in adults. As individuals age, their pulse rate tends to decrease due to changes in cardiovascular function.
Choice B is incorrect as the pulse rate typically decreases with age, rather than increases.
Choice C is incorrect as there is a general trend of decreasing pulse rate as individuals age, rather than a continuous variation.
Choice D is incorrect as the pulse rate does change over a patient's lifespan, starting fast in infants and decreasing as they age.