NCLEX-RN
NCLEX RN Simulated Exam Test Bank Questions
Extract:
Question 1 of 5
When providing mouth care to a patient in a coma, what should you do to provide good and safe mouth care?
Correct Answer: D
Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice
C) or using a foam swab only on the tongue (choice
B) may not provide the comprehensive mouth care necessary for patients in a coma.
Question 2 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 3 of 5
A patient who is displaying the defense mechanism of Compensation would:
Correct Answer: C
Rationale: The correct answer is 'Overemphasize behaviors which accommodate for perceived weaknesses.' Compensation involves overemphasizing or exaggerating a particular behavior or trait to make up for or cover up perceived weaknesses in oneself. This defense mechanism allows individuals to focus on their strengths rather than acknowledging their shortcomings.
Choices A, B, and D are incorrect. Refusing to hear unwanted information relates more to denial, transferring feelings of negativity to someone else is projection, and placing blame on others is an example of the defense mechanism known as externalization.
Question 4 of 5
When assessing a pulse, what should be noted?
Correct Answer: C
Rationale: When assessing a pulse, it is important to note the rate (number of beats per minute), quality (regular or irregular), and fullness (thread and weak or full and bounding). These aspects provide crucial information about the patient's cardiovascular status. Regularity, as mentioned in option D, is not typically assessed during a pulse check and is not necessary for routine pulse assessment.
Choice A is too limited as it overlooks important aspects beyond just the rate.
Choice B improves by adding quality but still lacks the fullness aspect.
Choice C is the most comprehensive and accurate as it includes all three essential aspects for a thorough pulse assessment.
Question 5 of 5
During an assessment, a nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?"? Which aspect of the mental status examination is the nurse assessing?
Correct Answer: B
Rationale: The nurse is assessing cognition in this scenario. Cognition involves evaluating a patient's judgment and decision-making abilities. By asking the patient what they would do in a specific situation, the nurse aims to determine the patient's cognitive function. A correct response indicating intact cognition would involve a decision like 'Call my doctor.' If the patient suggests inappropriate actions like 'I would stop eating' or 'I would just wait and see what happened,' it would suggest impaired judgment. The other options, behavior, affect and mood, and perceptual disturbances, refer to different aspects of the mental status examination and are not directly assessed through this question.