who is the center of care

NCLEX-RN

NCLEX RN Exam Prep

1. Who is the center of care?

A. The doctor
B. The administrator
C. The patient
D. The nurse

Correct answer: C

Rationale: The PATIENT is the center of care and the core of the healthcare team. The PATIENT holds the utmost importance within the healthcare setting. Healthcare professionals collaborate as a team to effectively address the needs of the patient. The primary focus should always be on the patient, who plays a crucial role in decision-making. While other healthcare team members, such as doctors, nurses, and administrators, play vital roles, the patient remains the central figure. The patient has the fundamental right to receive quality care from all members of the healthcare team.

2. During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?

A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulates in the hall
C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief

Correct answer: B

Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.

3. When examining an older adult, which technique should the nurse use?

A. Minimize touching the patient as much as possible.
B. Attempt to perform the entire physical examination during one visit.
C. Speak loudly and slowly due to potential hearing deficits in aging adults.
D. Arrange the sequence of the examination to allow as few position changes as possible.

Correct answer: D

Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.

4. An adult's blood pressure reads 40/20. You place the patient in a Trendelenberg position before rechecking the blood pressure. What actions will you take to position the patient correctly?

A. lower the head of the bed and raise the foot of the bed
B. raise the head of the bed up to about 60 to 75 degrees
C. raise the head of the bed up to about 75 to 90 degrees
D. raise the siderails and place the bed in the high position

Correct answer: A

Rationale: In a Trendelenberg position, used for low blood pressure, the correct action is to lower the head of the bed and raise the foot of the bed. This positioning facilitates the return of blood to the heart and helps increase blood pressure. Option B, raising the head of the bed to 60 to 75 degrees, is incorrect as it is not the Trendelenberg position. Option C, raising the head of the bed to 75 to 90 degrees, is incorrect as it does not align with the Trendelenberg position. Option D, raising the siderails and placing the bed in the high position, is incorrect as it does not address the specific positioning required for the Trendelenberg position.

5. A healthcare professional is preparing to administer a dose of platelets to a client. Which of the following actions must the healthcare professional perform before giving the platelets?

A. Start an IV of 0.9% Normal Saline to administer with the platelets
B. Ensure the container with the platelets is intact and not damaged
C. Verify the client's identity using two unique identifiers
D. Check the client's chart to ensure no contraindications to platelet transfusion

Correct answer: B

Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.