NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or healthcare providers, the nurse emphasizes interventions that do which of the following? (Berman & Snyder, 2012, p. 713)
Correct Answer: B
Rationale:
To prevent the spread of infection from a chronic carrier, the nurse should focus on blocking the portal of exit from the reservoir, which is the carrier person. By preventing the movement of the organism from the reservoir, the infection can be contained. Eliminating the reservoir is not feasible in this case as the carrier is a chronic carrier. Blocking the portal of entry into the host or decreasing the susceptibility of the host would only impact individual prevention and not the spread from the carrier to others.
Question 2 of 5
A patient's urine specimen tested positive for bilirubin. Which of the following is most true?
Correct Answer: D
Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing.
Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease.
Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels.
Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.
Question 3 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.
Question 4 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 5 of 5
The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?
Correct Answer: C
Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. During the implementation phase, the nurse puts the care plan into action, which includes coordinating with other healthcare team members like the physical therapy department. Assessment involves data gathering, planning involves goal setting, and evaluation involves determining the attainment of client goals.