a nurse 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
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Nursing Elites

NCLEX-RN

NCLEX RN Predictor Exam

1. 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?

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.

2. What action by the nurse is appropriate when examining a 16-year-old male teenager?

Correct answer: D

Rationale: During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.

3. A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?

Correct answer: A

Rationale: When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.

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?

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. A nurse is preparing to change a client's dressing for a burn wound on his foot. Which of the following interventions is appropriate for this process?

Correct answer: A

Rationale: When changing the dressing for a burn wound, it is essential to follow appropriate interventions to prevent infection, reduce pain, and support healing. In this scenario, after removing the old dressing, it is crucial to wash the wound gently with a suitable cleanser, rinse the area thoroughly, and then pat it dry. This process helps in maintaining cleanliness, reducing the risk of infection, and providing a conducive environment for healing. Binding the wound tightly (Choice B) can impede circulation and delay healing. Contacting the physician after the dressing change (Choice C) may be necessary in specific situations but is not a standard step in routine dressing changes. Providing analgesics after the procedure (Choice D) is important for pain management but is not directly related to the dressing change itself.

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