NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
Which of the following lists the recommended sequence for removing soiled personal protective equipment when preparing to leave a patient's room?
Correct Answer: D
Rationale: The correct sequence for removing soiled personal protective equipment is crucial to prevent contamination. Gloves should always be removed first as they are most likely to be contaminated. Following the removal of gloves, goggles, gown, mask, and finally washing hands is recommended.
Choice A is incorrect as gloves should be removed first.
Choice B is incorrect as the sequence is not in the recommended order.
Choice D is incorrect as gloves should be removed before goggles.
Question 2 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 3 of 5
A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at the time of admission?
Correct Answer: B
Rationale: The most essential measure when admitting a client who had a seizure is to pad the bed with blankets (Option
B). This is crucial to prevent injury in case of another seizure. Placing a padded tongue depressor at the head of the bed (Option
A) is incorrect as current nursing guidelines advise against putting anything in the client's mouth during a seizure. Informing the client about wearing a medical identification tag (Option
C) and teaching the client about seizures (Option
D) are important but are more relevant once the cause of the seizure is known. It's crucial to remember that not all seizures are classified as epilepsy.
Question 4 of 5
During a general survey of a patient, which finding is considered normal?
Correct Answer: A
Rationale: A body mass index (BMI) of 20 is considered normal as the range for a normal BMI is between 19-24. When standing, a patient's base should be wide for stability and proper weight distribution. An older appearance than the stated age may indicate a history of chronic illness or chronic alcoholism. In a general survey, the patient's arm span (fingertip to fingertip) should approximately equal the patient's height. An arm span greater than the height may suggest Marfan syndrome.
Therefore, the correct choice is a normal BMI of 20, which falls within the healthy range.
Choices B, C, and D all describe abnormal findings that may indicate underlying health conditions or syndromes.
Question 5 of 5
Which is the most effective action for controlling the spread of infection?
Correct Answer: A
Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.