NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?
Correct Answer: C
Rationale: When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant's hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.
Question 2 of 5
When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?
Correct Answer: D
Rationale: The nurse needs to assess the cultural beliefs and practices of the patient and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication.
Therefore, the most appropriate question to initiate an assessment of cultural beliefs with an older American Indian patient is "What cultural or spiritual beliefs are important to you?"? This question shows respect for the patient's beliefs and encourages them to share relevant information. Asking if they are of the Christian faith does not promote open communication and may not reflect the patient's actual beliefs. While some American Indians may seek assistance from a medicine man or shaman, it is not appropriate to make assumptions without direct input from the patient. Asking how often they seek help from medical providers is not directly related to understanding their cultural beliefs and may not provide relevant insights for culturally competent care.
Question 3 of 5
A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This situation illustrates which concept?
Correct Answer: B
Rationale: Assimilation is a unidirectional, linear process moving from unacculturated to acculturated, in which a person develops a new cultural identity and becomes like members of the dominant culture. In this scenario, the woman has adapted to the new culture by learning the language, dressing like her peers, and expressing that her family in Europe would hardly recognize her. This aligns with the process of assimilation. Integration and biculturalism, on the other hand, involve bidirectional and bidimensional processes that induce reciprocal change in both cultures while maintaining aspects of the original culture in one's ethnic identity. Since there is no indication in the question that the woman has retained aspects of her original culture, integration and biculturalism are not the correct concepts. Heritage consistency refers to the degree to which one retains their original or traditional culture, which is not addressed in the scenario provided.
Question 4 of 5
What is the most important step that healthcare personnel can take to prevent the transmission of microorganisms in the hospital setting?
Correct Answer: C
Rationale: The most crucial step in preventing the transmission of microorganisms in the hospital setting is proper hand hygiene. Healthcare personnel should wash their hands thoroughly before and after each patient contact to reduce the risk of spreading infections. While cleaning the stethoscope with an alcohol swab between patients is recommended, it is secondary to hand hygiene. Wearing protective eyewear at all times is not necessary for routine patient care unless specifically indicated, and wearing gloves only when in direct contact with patients is important but not as critical as proper handwashing.
Therefore, the correct answer is to wash hands before and after contact with each patient.
Question 5 of 5
Which of these statements is true regarding the use of Standard Precautions in the healthcare setting?
Correct Answer: C
Rationale: Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources. They are intended for use with all patients, regardless of their risk or presumed infection status. Standard Precautions apply to all body fluids, secretions, and excretions except sweat - whether or not they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled.
Choice A is incorrect because Standard Precautions apply to all body fluids, secretions, and excretions except sweat.
Choice B is incorrect because alcohol-based hand rub should be used when hands are not visibly dirty.
Choice D is incorrect because Standard Precautions are not limited to situations involving non-intact skin, excretions with visible blood, or expected mucous membrane contact.