a child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot t

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A. The admission orders are written.
B. A blood culture is drawn.
C. A complete blood count with differential is drawn.
D. The parents arrive.

Correct answer: A blood culture is drawn.

Rationale: Before starting antibiotics, a blood culture should be drawn to identify the causative organism. This step is crucial as antibiotics may interfere with the identification process. Drawing a complete blood count with differential or writing admission orders are important steps in patient care but are not as critical as obtaining a blood culture to guide appropriate antibiotic therapy. The arrival of the parents is not directly related to the immediate action required before starting antibiotics in this scenario.

2. Which of the following lists the recommended sequence for removing soiled personal protective equipment when preparing to leave a patient's room?

A. Gown, goggles, mask, gloves, and exit the room.
B. Gloves, wash hands, remove gown, mask, and goggles.
C. Gloves, goggles, gown, mask, and wash hands.
D. Gloves, goggles, gown, mask, and wash hands.

Correct answer: Gloves, goggles, gown, mask, and wash hands.

Rationale: The correct sequence for removing soiled personal protective equipment is crucial to prevent contamination. Gloves should always be removed first as they are most likely to be contaminated. Following the removal of gloves, goggles, gown, mask, and finally washing hands is recommended. Choice A is incorrect as gloves should be removed first. Choice B is incorrect as the sequence is not in the recommended order. Choice D is incorrect as gloves should be removed before goggles.

3. Which is the most effective action for controlling the spread of infection?

A. Thorough hand hygiene
B. Wearing gloves and masks when providing direct client care
C. Implementing appropriate isolation precautions
D. Administering broad-spectrum prophylactic antibiotics

Correct answer: Thorough hand hygiene

Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.

4. The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature—36°C; pulse—48 beats per minute; respirations—14 breaths per minute; blood pressure—104/68 mm Hg. Which statement is true concerning these results?

A. The patient is experiencing bradycardia.
B. These are normal vital signs for a healthy, athletic adult.
C. The patient’s pulse rate is not normal—no action is required.
D. The patient's next clinic visit should occur as scheduled.

Correct answer: These are normal vital signs for a healthy, athletic adult.

Rationale: The correct answer is, 'These are normal vital signs for a healthy, athletic adult.' A pulse rate of 48 beats per minute is considered bradycardia in adults, but it is not a concern in well-trained athletes like marathon runners. Bradycardia is a normal physiological response to aerobic conditioning. Tachycardia, on the other hand, is defined as a pulse rate above 100 beats per minute, which is not the case here. The low pulse rate in this scenario is a reflection of the athlete's cardiovascular fitness. Therefore, there is no need to notify the physician or schedule a follow-up visit based on these findings.

5. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?

A. ''This action of my lips helps to keep my airway open.''
B. ''I can expel more air when I pucker up my lips to breathe out.''
C. ''My mouth doesn't get as dry when I breathe with pursed lips.''
D. ''By prolonging breathing out with pursed lips, the smaller areas in my lungs don't collapse.''

Correct answer: ''By prolonging breathing out with pursed lips, the smaller areas in my lungs don't collapse.''

Rationale: The correct answer is D. Clients with chronic obstructive pulmonary disease have difficulty exhaling fully due to the weak alveolar walls from the disease process. Pursed-lip breathing helps prevent alveolar collapse by maintaining positive pressure in the airways during exhalation. This is the major reason for using pursed-lip breathing in individuals with chronic obstructive lung disease. Choices A, B, and C are incorrect because they do not directly address the main purpose of pursed-lip breathing, which is to prevent alveolar collapse and improve exhalation in these patients.