NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
When printing out an EKG, a nurse notices that the QRS complexes are extremely small. What should be the next step?
Correct Answer: C
Rationale: Increasing the sensitivity control to 20 mm deflection will double the sensitivity, allowing for better observation of the small QRS complexes. This step is crucial in obtaining a clearer EKG reading.
Choice A is incorrect because small QRS complexes do not necessarily indicate impending cardiac arrest; it's more likely a technical issue.
Choice B is not the first step to take when small QRS complexes are observed; it's important to adjust the settings first.
Choice D is incorrect because decreasing the run speed to 50 is not the appropriate action for this situation; adjusting the sensitivity control is more relevant to improve the visualization of the complexes.
Question 2 of 5
Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?
Correct Answer: A
Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.
Question 3 of 5
A patient with Parkinson's disease is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care?
Correct Answer: B
Rationale: When a person experiences dysphagia (difficulty swallowing), the greatest concern is aspiration. Aspiration occurs when food or fluids enter the trachea and lungs instead of going down the esophagus. This can lead to serious complications such as choking, airway obstruction, and aspiration pneumonia. Anorexia (
Choice
A) refers to a loss of appetite, which is not the primary concern with dysphagia. Self-care deficit (
Choice
C) and inadequate intake (
Choice
D) are important considerations but do not have as direct an impact on the immediate safety and health risks associated with aspiration in dysphagia.
Question 4 of 5
A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?
Correct Answer: D
Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.
Question 5 of 5
Which of the following tests would MOST LIKELY be performed on a patient who is being monitored for coagulation therapy?
Correct Answer: A
Rationale: The correct answer is A: PT/INR. Prothrombin times (PT/INR) are commonly used to monitor patients on Coumadin (warfarin) therapy, an anticoagulant that slows the blood's ability to clot. Monitoring PT/INR levels helps ensure the patient is receiving the appropriate dosage of Coumadin.
Choice B, CBC (Complete Blood Count), is a general test that provides information on red blood cells, white blood cells, and platelets but is not specific to monitoring coagulation therapy.
Choice C, PTT (Partial Thromboplastin Time), is another coagulation test but is not as commonly used for monitoring Coumadin therapy.
Choice D, WBC (White Blood Cell count), is unrelated to monitoring coagulation therapy and is used to assess immune system function.