NCLEX-RN
Exam Cram NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?
Correct Answer: B
Rationale: Before starting antibiotics, a blood culture should be drawn to identify the causative organism. This step is crucial as antibiotics may interfere with the identification process. Drawing a complete blood count with differential or writing admission orders are important steps in patient care but are not as critical as obtaining a blood culture to guide appropriate antibiotic therapy. The arrival of the parents is not directly related to the immediate action required before starting antibiotics in this scenario.
Question 2 of 5
What technique would the nurse use to accurately assess a rectal temperature in an adult?
Correct Answer: A
Rationale:
To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes.
Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate.
Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort.
Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.
Question 3 of 5
During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?
Correct Answer: C
Rationale: When prioritizing patient assessments, the nurse should address the patient with cirrhosis and ascites who has an elevated oral temperature of 102°F (38.8°
C) first. This presentation suggests a potential infection, which is critical to address promptly in a patient with liver disease. An infection in a patient with cirrhosis can quickly progress to severe complications. The other options, such as chronic pancreatitis with abdominal pain, compensated cirrhosis with anorexia, and post-laparoscopic cholecystectomy with shoulder pain, do not indicate an immediate life-threatening situation requiring urgent assessment compared to a possible infection in a patient with cirrhosis and ascites.
Question 4 of 5
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to an LPN/LVN?
Correct Answer: B
Rationale: The correct answer is to delegate the task of setting up oxygen and suction equipment to the LPN/LVN. This task falls within their scope of practice and can be safely performed by them. Completing the admission assessment (
Choice
A) typically requires a higher level of assessment and critical thinking, making it more appropriate for a registered nurse. Placing a padded tongue blade at the bedside (
Choice
C) involves potential airway management, which is a more complex task and should be done by a higher-level provider. Padding the side rails before the patient arrives (
Choice
D) is a task related to patient safety and should be done by the healthcare team as a whole, not solely delegated to an LPN/LVN.
Question 5 of 5
A patient in a clinic has been diagnosed with hepatitis A. What is the most likely route of transmission?
Correct Answer: B
Rationale: The correct answer is contaminated food. Hepatitis A is primarily transmitted through the fecal-oral route, often through the ingestion of contaminated food or water. It is caused by the Hepatitis A virus (HAV), which is a single-stranded, positive-sense RNA virus. Sexual contact with an infected partner is more commonly associated with hepatitis B and C. Blood transfusion is a potential route for hepatitis B and C transmission due to bloodborne pathogens. Illegal drug use, particularly involving shared needles, is a common route for hepatitis C transmission.