NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?
Correct Answer: A
Rationale: Excess secretions from the tracheostomy tube can collect near the stomal opening and cause skin breakdown. Management of secretions through regular suctioning will keep the area clean and dry, minimizing skin irritation.
Choice B, cleansing the site daily with povidone-iodine and water, is incorrect as it may lead to skin irritation due to the harshness of povidone-iodine.
Choice C, avoiding tube ties to secure the tube, is also incorrect as securing the tube is essential for stability.
Choice D, 'None of the above,' is incorrect as managing secretions through suctioning is crucial in preventing skin irritation.
Question 2 of 5
A 36-year-old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?
Correct Answer: A
Rationale: The correct action by the nurse is to schedule the patient for HCV genotype testing. Genotyping of HCV is crucial in determining the appropriate treatment regimen and guiding therapy decisions. Most patients with acute HCV infection progress to the chronic stage, so it is incorrect to inform the patient that the infection will resolve in a few months. There is no vaccine or immune globulin available for HCV, and ribavirin (Rebetol) is typically used for chronic HCV infection.
Therefore, the nurse should prioritize genotyping to assist in treatment planning.
Question 3 of 5
Which of the following interventions should the nurse use when working with a Jackson-Pratt drain?
Correct Answer: C
Rationale: A Jackson-Pratt drain is a type of active wound drain that may be placed following a surgical procedure. This drain actively draws excess blood and fluid out of the wound. If clots develop within the tubing, the nurse should strip the tubing by milking it in a direction away from the client. This action helps to ensure the drain remains patent and effective. Option A is incorrect because the tubing should be milked away from the client, not towards. Option B is incorrect as the drain should be emptied based on the healthcare provider's orders, not at a fixed volume. Option D is incorrect because the level of the drain should be below the level of the incision to allow drainage by gravity.
Question 4 of 5
A client has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?
Correct Answer: D
Rationale: A client diagnosed with active tuberculosis should be placed in isolation in a negative-pressure room to prevent transmission of infection to others. Placing the client in a negative-pressure room ensures that air is exhausted to the outside and received from surrounding areas, preventing tuberculin particles from traveling through the ventilation system and infecting others. Initiating standard precautions, as mentioned in choice C, is essential for infection control but is not specific to preventing transmission in the case of tuberculosis. Beginning drug therapy within 72 hours of diagnosis, as in choice A, is crucial for the treatment of tuberculosis but does not directly address preventing transmission. Placing the client in a positive-pressure room, as in choice B, is incorrect as positive-pressure rooms are used for clients with compromised immune systems to prevent outside pathogens from entering the room, which is not suitable for a client with active tuberculosis.
Question 5 of 5
The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?
Correct Answer: B
Rationale: The correct answer is that clients with HIV must take their medications exactly as prescribed. Antiretrovirals need to be taken as directed to prevent the development of drug-resistant strains and maintain treatment effectiveness. Missing doses can compromise the effectiveness of future treatments.
Choice A, informing household members, is important for social support but not the most critical aspect of managing the condition.
Choice C, abstaining from substance use, is important but not as crucial as medication adherence.
Choice D, avoiding large crowds, is not directly related to HIV management as long as the individual's immune system is not significantly compromised.