NCLEX RN Predictor Exam - Nurselytic

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.

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.

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.

Correct Answer: B

Rationale: When a person experiences dysphagia (difficulty swallowing), the greatest concern is aspiration. Aspiration occurs when food or fluids enter the trachea and lungs instead of going down the esophagus. This can lead to serious complications such as choking, airway obstruction, and aspiration pneumonia. Anorexia (
Choice
A) refers to a loss of appetite, which is not the primary concern with dysphagia. Self-care deficit (
Choice
C) and inadequate intake (
Choice
D) are important considerations but do not have as direct an impact on the immediate safety and health risks associated with aspiration in dysphagia.

Correct Answer: A

Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.