NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?
Correct Answer: D
Rationale: In this scenario, the nurse has observed concerning signs in the client during the transfer process. The appropriate action for reassessment would be to observe the client's skin color and take another set of vital signs. This will provide essential data to evaluate the client's condition more accurately. Options A, B, and C are interventions that do not address the need for reassessment. Moving the client more quickly, documenting previous vital signs, or returning the client to bed do not directly address the need to reassess the client's current condition.
Question 2 of 5
For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?
Correct Answer: B
Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.
Question 3 of 5
After performing the appropriate client assessment, which of the following inferences would the nurse make?
Correct Answer: A
Rationale: An inference is the nurse's judgment or interpretation of cues gathered during an assessment. In this scenario, identifying a client as hypotensive would be an inference based on blood pressure readings that indicate lower than normal values. Respiratory rate and oxygen saturation levels (choices B and
C) are important cues that provide additional data but do not directly point to a specific conclusion like hypotension. The client expressing anxiety about blood work (choice
D) is relevant information but relates more to their emotional state rather than a physiological assessment finding.
Question 4 of 5
A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?
Correct Answer: C
Rationale:
To confirm glucosuria, the most appropriate method is to run a Clinitest. Clinitest tablets are specifically designed to detect glucose in urine samples. This test is particularly useful when the urine is discolored, making it challenging to accurately assess the color change.\n
Choice A, using a hand-held glucometer, is not the standard method for confirming glucose in urine; these devices are primarily used for blood glucose monitoring.\n
Choice B, having another Medical Assistant perform a repeat dipstick test, may not provide a more definitive confirmation as dipstick tests can sometimes yield false positives or be less accurate compared to other methods like the Clinitest.\n
Choice D, running an Acetest, is used to detect ketones in the urine, not glucose. Ketones are typically associated with conditions like diabetic ketoacidosis, which is different from glucosuria.
Question 5 of 5
A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at the time of admission?
Correct Answer: B
Rationale: The most essential measure when admitting a client who had a seizure is to pad the bed with blankets (Option
B). This is crucial to prevent injury in case of another seizure. Placing a padded tongue depressor at the head of the bed (Option
A) is incorrect as current nursing guidelines advise against putting anything in the client's mouth during a seizure. Informing the client about wearing a medical identification tag (Option
C) and teaching the client about seizures (Option
D) are important but are more relevant once the cause of the seizure is known. It's crucial to remember that not all seizures are classified as epilepsy.