Exam Cram NCLEX RN Practice Questions

Extract:

Question 1 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.

Question 2 of 5

A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?

A. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise. B. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus dysrhythmia. C. The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. D. The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.

Correct Answer: B

Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic lood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.
An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate an apical heart rate, not palpate a radial pulse, with infants and toddlers.

Question 3 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?

A. Complete admission assessment. B. Set up oxygen and suction equipment. C. Place a padded tongue blade at the bedside. D. Pad the side rails before the patient arrives.

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 4 of 5

When a sequence of repeated weights is necessary, the healthcare provider should aim to weigh the patient at the same time of day and with consistent clothing. Using a standardized balance or electronic standing scale is recommended for accurate measurements. The patient should remove shoes and heavy outer clothing. It is not required for the patient to always be weighed in undergarments. What is the most appropriate indicator of the patient's overall well-being?

A. General health B. Genetic makeup C. Nutritional status D. Activity and exercise patterns

Correct Answer: A

Rationale: Weight measurements are essential to assess general health, particularly in monitoring growth patterns. Height and weight recordings are crucial indicators of overall well-being, reflecting the individual's health status. Genetic makeup does not change with weight fluctuations, making it an inappropriate indicator. Nutritional status and activity levels can influence weight but are not as comprehensive as general health in reflecting overall well-being.

Question 5 of 5

Patients who cannot move in their bed on their own should be turned at least ________________.

A. once a day B. twice a day C. every 2 hours D. every 4 hours

Correct Answer: C

Rationale: Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications.
Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.

Exam Cram NCLEX RN Practice Questions - Nurselytic

Nurselytic

NCLEX-RN

NCLEX-RN