NCLEX RN Predictor Exam

Extract:

Question 1 of 5

Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?

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.

Question 2 of 5

A healthcare professional is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?

A. Patient who is receiving chemotherapy for liver cancer B. Patient who is receiving chemotherapy for lung cancer C. Patient who has a wound infection after cholecystectomy D. Patient who requires pain management for chronic pancreatitis

Correct Answer: D

Rationale: The patient with chronic pancreatitis is the best choice to admit to the same room as a patient who had a liver transplant and is experiencing acute rejection. This is because the patient with chronic pancreatitis does not pose an infection risk to the immunosuppressed patient who had a liver transplant. On the other hand, patients receiving chemotherapy for cancer or those with wound infections are at risk for infections, which could endanger the immunosuppressed patient with acute rejection.

Question 3 of 5

A patient has come to the office for a blood draw. The patient starts to sweat and is very anxious. Which of the following would be the BEST way to proceed?

A. Do not perform the procedure. Notify the physician of the reason why. B. Perform the procedure but pay close attention for signs of potential syncope. C. Allow the patient to reschedule for a time when he isn't as anxious. D. Have the physician draw the blood.

Correct Answer: B

Rationale: In the scenario where a patient is sweating and anxious, it is important to assess for signs of potential syncope (fainting) while proceeding with the blood draw. If the patient does not exhibit signs of fainting, the phlebotomy procedure can be performed safely. Postponing the procedure may not address the patient's anxiety and inconvenience them. Having the physician draw the blood is not necessary if the phlebotomist can handle the situation effectively.

Question 4 of 5

A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

A. Help the client to get settled and conduct the interview the next morning when the client is rested B. Conduct the interview immediately, directing the majority of the questions to the client C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

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.

Question 5 of 5

The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.

A. Client has an actual health problem B. Client has a wellness diagnosis C. Collaborative health problem needs to be written D. Possible nursing diagnosis exists

Correct Answer: B

Rationale: The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.

NCLEX RN Predictor Exam - Nurselytic

Nurselytic

NCLEX-RN

NCLEX-RN