NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
Which of the following descriptors is most appropriate to use when stating the 'problem' part of a nursing diagnosis?
Correct Answer: B
Rationale: The problem part of a nursing diagnosis in the context of nursing care plans should focus on the client's response to a life process, event, or stressor. This response is what is used to identify the nursing diagnosis. 'Anxiety' is the most appropriate descriptor for the problem part of a nursing diagnosis as it reflects a psychological response that can be addressed by nursing interventions. 'Grimacing' is a physical manifestation and not the problem itself. 'Oxygenation saturation 93%' and 'Output 500 mL in 8 hours' are data points or cues that a nurse would use to formulate the nursing diagnostic statement, not the actual problem being addressed.
Question 2 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 3 of 5
For a patient who is blood type AB, which blood product can they receive?
Correct Answer: C
Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens.
Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma.
Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens.
Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type.
Therefore, choices A and B are incorrect, and the correct choice is C.
Question 4 of 5
When are manual hematocrits done?
Correct Answer: D
Rationale: Manual hematocrits are performed to monitor anemia, which involves measuring the percentage of red blood cells in the blood. The process involves collecting blood in a microhematocrit tube, then centrifuging it to separate the plasma from the cells. By measuring the ratio of plasma to cells, healthcare providers can assess the patient's hematocrit level.
Therefore, all the provided options are correct as they collectively describe the purpose and procedure of manual hematocrits.
Question 5 of 5
The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?
Correct Answer: A
Rationale: In this scenario, the nurse is cautious about potential diagnostic errors due to incomplete data. When a client withholds information, it can lead to incomplete data, which may result in inaccurate nursing diagnoses and care planning.
Therefore, the nurse's primary concern is collecting accurate data to make informed clinical decisions.
Choices B, C, and D are not relevant to the situation described. Generalizing from experience, identifying with the client, and lack of clinical experience do not directly address the issue of incomplete data impacting the diagnostic process.