NCLEX RN Predictor Exam

Extract:

Question 1 of 5

During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?

Correct Answer: B

Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.

Question 2 of 5

Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?

A. Vest restraints should be used because they are the least restrictive type. B. Restraints should be used for 48 hours in non-psychiatric patients. C. Restraints should be applied to prevent wandering behavior. D. Alternative measures must be attempted first.

Correct Answer: D

Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.

Question 3 of 5

A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

A. Help the client to get settled and conduct the interview the next morning when the client is rested B. Conduct the interview immediately, directing the majority of the questions to the client C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

Correct Answer: C

Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (
Choice
A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (
Choice
B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (
Choice
D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.

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

The rehabilitation nurse wishes to make the following entry into a client's plan of care: 'Client will reestablish a pattern of daily bowel movements without straining within two months.' The nurse would write this statement under which section of the plan of care?

A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals

Correct Answer: D

Rationale: The correct answer is 'Long-term goals.' Long-term goals are designed to describe changes in client behavior expected over a time frame greater than one week. In this case, the goal of reestablishing a pattern of daily bowel movements without straining within two months falls under a long-term goal. Long-term goals are aimed at restoring normal functioning in a problem area and are beneficial for healthcare workers caring for the client across different settings.

Choices A, B, and C are incorrect because nursing diagnosis/problem list, nursing orders, and short-term goals do not encompass the desired timeframe or level of expected change in this scenario.

NCLEX RN Predictor Exam - Nurselytic

Nurselytic

NCLEX-RN

NCLEX-RN