NCLEX RN Predictor Exam

Question 1 of 5

Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting?

A. Keep all of the side rails up B. Review prescribed medications C. Complete the "get up and go"? test D. Place the bed in the lowest position

Correct Answer: D

Rationale: The highest priority nursing intervention for a client at risk for falls in a hospital setting is to place the bed in the lowest position. This action ensures that the client falls the shortest distance, reducing the risk of injury. Keeping all side rails up (Option
A) may lead to a fall with injury, as the client might attempt to get over the rail and fall from a higher distance. Reviewing prescribed medications (Option
B) is important as certain medications can increase the risk of falling, but it is not the best answer as it is not applicable to all clients. Completing the "get up and go"? test (Option
C) can help assess a client's risk for falling but does not directly prevent injury.

Question 2 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?

A. Incomplete data B. Generalizing from experience C. Identifying with the client D. Lack of clinical experience

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.

Question 3 of 5

The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?

A. The child is asked to undress from the waist up. B. The head is examined before the thorax, abdomen, and genitalia. C. The nurse should keep in mind that a child at this age will have a sense of modesty. D. Talking about the equipment being used is avoided to prevent increasing the child's anxiety.

Correct Answer: C

Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment.
Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.

Question 4 of 5

A healthcare professional is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?

A. Patient who is receiving chemotherapy for liver cancer B. Patient who is receiving chemotherapy for lung cancer C. Patient who has a wound infection after cholecystectomy D. Patient who requires pain management for chronic pancreatitis

Correct Answer: D

Rationale: The patient with chronic pancreatitis is the best choice to admit to the same room as a patient who had a liver transplant and is experiencing acute rejection. This is because the patient with chronic pancreatitis does not pose an infection risk to the immunosuppressed patient who had a liver transplant. On the other hand, patients receiving chemotherapy for cancer or those with wound infections are at risk for infections, which could endanger the immunosuppressed patient with acute rejection.

Question 5 of 5

In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions?

A. Droplet precautions B. Airborne precautions C. Contact precautions D. Universal precautions

Correct Answer: A

Rationale: Rubella is an illness transmitted by large-particle droplets, so the nurse should implement droplet precautions in addition to standard precautions. Airborne precautions are used for diseases spread through small particles in the air, such as tuberculosis, varicella, and rubeola. Contact precautions are utilized for diseases transmitted by direct contact with the patient or their environment. Universal precautions and body substance isolations are part of the CDC's standard precautions recommendations, but do not specifically address the transmission route of rubella.

Nurselytic

NCLEX-RN

NCLEX-RN