NCLEX-RN
NCLEX RN Exam Prep Questions
Extract:
Question 1 of 5
When assisting a client with shampooing his hair while he is still in bed, a nurse raises the bed to approximately the level of her waist. What is the rationale for this action?
Correct Answer: C
Rationale: Raising the bed to the level of the nurse's waist while assisting a client with shampooing in bed is done to reduce strain on the nurse's back. This adjustment ensures that the nurse can work comfortably without excessive bending or stooping, thus preventing back injuries.
Choices A, B, and D are incorrect. While preventing shampoo from getting into the client's eyes, allowing excess water to run off the bed, and preventing hair tangles are important considerations, the primary rationale for raising the bed is to prioritize the nurse's ergonomic safety and prevent musculoskeletal strain.
Question 2 of 5
Which of the following is NOT an acceptable abbreviation?
Correct Answer: A
Rationale: The correct answer is A: D/C. D/C is not an acceptable abbreviation as it can be easily confused with both 'discharge' and 'discontinue.' The abbreviations 'tid' (three times a day), 'bid' (twice a day), and 'qid' (four times a day) are commonly used in medical contexts to indicate dosing frequencies and are widely accepted in healthcare settings.
Question 3 of 5
Which statement best describes evidence-based practice?
Correct Answer: D
Rationale: Evidence-based practice involves utilizing the most effective, current, and relevant information to inform nursing care decisions for optimal client outcomes. While research reports and data collection are important components of evidence-based practice, the essence lies in integrating all available information to determine the best course of action. Monitoring compliance with standards, as described in choices A and C, is essential for quality assurance but does not capture the comprehensive nature of evidence-based practice.
Question 4 of 5
Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?
Correct Answer: D
Rationale: The correct answer is D. Clients with chronic obstructive pulmonary disease have difficulty exhaling fully due to the weak alveolar walls from the disease process. Pursed-lip breathing helps prevent alveolar collapse by maintaining positive pressure in the airways during exhalation. This is the major reason for using pursed-lip breathing in individuals with chronic obstructive lung disease.
Choices A, B, and C are incorrect because they do not directly address the main purpose of pursed-lip breathing, which is to prevent alveolar collapse and improve exhalation in these patients.
Question 5 of 5
A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?
Correct Answer: C
Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.