NCLEX-RN
NCLEX RN Exam Preview Answers Questions
Extract:
Question 1 of 5
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is the 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath. Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism, which requires immediate assessment and action such as oxygen administration to maintain adequate oxygenation. The other patients should also be assessed as soon as possible, but they do not present with an immediate life-threatening condition that requires urgent intervention like the patient experiencing sudden shortness of breath.
Question 2 of 5
Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:
Correct Answer: C
Rationale: A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **
Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **
Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **
Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.
Question 3 of 5
What is the most important step that healthcare personnel can take to prevent the transmission of microorganisms in the hospital setting?
Correct Answer: C
Rationale: The most crucial step in preventing the transmission of microorganisms in the hospital setting is proper hand hygiene. Healthcare personnel should wash their hands thoroughly before and after each patient contact to reduce the risk of spreading infections. While cleaning the stethoscope with an alcohol swab between patients is recommended, it is secondary to hand hygiene. Wearing protective eyewear at all times is not necessary for routine patient care unless specifically indicated, and wearing gloves only when in direct contact with patients is important but not as critical as proper handwashing.
Therefore, the correct answer is to wash hands before and after contact with each patient.
Question 4 of 5
When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse would take when performing a physical examination?
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when performing a physical examination is to wash their hands before and after every physical patient encounter. This practice helps prevent the spread of infection. Hands should also be washed after contact with blood, body fluids, secretions, and excretions, and after contact with any equipment contaminated with body fluids. It is crucial to wash hands after removing gloves, even if the gloves appear intact.
Choice A is incorrect because washing hands after removing gloves is necessary to ensure thorough hygiene.
Choice C is incorrect because hands should be washed before and after every patient encounter, not just before examining each body system.
Choice D is incorrect because gloves should be worn when there is potential contact with body fluids, but they do not need to be worn throughout the entire examination.
Question 5 of 5
What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?
Correct Answer: C
Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices.
Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs.
Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care.
Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.