NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of 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.
Question 2 of 5
For a patient who is blood type AB, which blood product can they receive?
Correct Answer: C
Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens.
Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma.
Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens.
Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type.
Therefore, choices A and B are incorrect, and the correct choice is C.
Question 3 of 5
The nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range?
Correct Answer: C
Rationale: Restraints should be removed every 2 hours to prevent complications. Moving the joints through their full range of motion helps prevent muscle shortening and contractures. Massaging the area promotes circulation and reduces the risk of pressure injuries. Removing restraints less frequently could lead to complications like decreased circulation and skin breakdown. Options A, B, and D are incorrect because they do not align with the standard practice of removing restraints every 2 hours to ensure patient safety and well-being.
Question 4 of 5
Which of the following items of subjective client data would be documented in the medical record by the nurse?
Correct Answer: D
Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition.
Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse.
Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.
Question 5 of 5
For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?
Correct Answer: D
Rationale: The correct answer is 'Fractured wrists.' In a nursing diagnostic statement, the related factor or risk factor is the underlying cause of the identified problem. In this case, the major factor affecting the self-care deficit in feeding is the bilateral fractured wrists in casts. The fractured wrists directly impact the client's ability to feed themselves, making it the primary related factor.
Choices A, B, and C are incorrect as discomfort, deficit, and feeding are not the primary cause of the feeding problem in this scenario; rather, it is the physical limitation caused by the fractured wrists that is the focus of the nursing intervention.