NCLEX-RN
NCLEX RN Exam Prep
1. The nurse should wash from the ________________________ when washing a patient's eye area.
- A. outer canthus to the inner canthus
- B. inner canthus to the outer canthus
- C. internal nares to the external nares
- D. external nares to the internal nares
Correct answer: B
Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.
2. What does preload refer to?
- A. The volume of blood entering the left side of the heart
- B. The volume of blood entering the right side of the heart
- C. The pressure in the venous system that the heart must overcome to pump the blood
- D. The pressure in the arterial system that the heart must overcome to pump the blood
Correct answer: B
Rationale: Preload refers to the volume of blood that enters the right side of the heart. This volume stretches the fibers in the heart before contraction. Preload is an essential factor in determining the force of ventricular contraction. Choices A, C, and D are incorrect. Choice A is incorrect because preload is specifically related to the volume of blood entering the right side of the heart. Choices C and D are incorrect as they refer to afterload, which is the pressure that the heart must overcome to pump blood out of the ventricles into the systemic or pulmonary circulation.
3. While caring for Mrs. Thomas, you see a notation on the nursing care plan that states 'ambulate at least 10 yards qid'. This patient will be assisted with ambulation at which of the following times?
- A. 10:00 AM
- B. 10 am and 2 pm
- C. 10 am and 2 pm
- D. 10 am, 2 pm, 6 pm, and 10 pm
Correct answer: D
Rationale: The correct answer is to assist the patient with ambulation at 10 am, 2 pm, 6 pm, and 10 pm as qid stands for four times per day. This schedule is commonly followed in healthcare facilities to ensure regular ambulation and exercise for the patient. Choices A, B, and C do not cover all the specified times for ambulation as indicated by the qid notation on the care plan.
4. 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?
- A. To prevent shampoo from getting into the client's eyes
- B. To allow excess water to run off the edge of the bed
- C. To decrease strain on the nurse's back
- D. To prevent the client's hair from developing tangles
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.
5. Which of the following statements best describes footdrop?
- A. The foot is permanently fixed in the dorsiflexion position
- B. The foot is permanently fixed in the plantar flexion position
- C. The toes of the foot are permanently fanned
- D. The heel of the foot is permanently rotated outward
Correct answer: B
Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.
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