NCLEX-RN
NCLEX RN Exam Prep
1. A nursing care plan states, 'Assist the patient to the bedside commode PRN.' When will this patient get this assistance to the commode?
- A. Whenever needed
- B. At bedtime
- C. During the night
- D. During the day
Correct answer: A
Rationale: The correct answer is 'Whenever needed.' The abbreviation 'PRN' stands for 'pro re nata,' which translates to 'as needed' or 'whenever necessary.' This means that the patient will receive assistance to the commode whenever they require it, based on their individual needs and condition. Choices B, C, and D are incorrect because 'PRN' does not specify a specific time like bedtime, during the night, or during the day; instead, it indicates assistance based on the patient's needs.
2. A healthcare professional is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?
- A. Cephalic
- B. Median cubital
- C. Basilic
- D. All of the above
Correct answer: D
Rationale: The correct answer is 'All of the above.' All three of these veins - the cephalic, median cubital, and basilic veins - are located in the antecubital space, which is the area in front of the elbow on the arm. The cephalic vein runs along the outer side of the arm, the basilic vein runs along the inner side of the arm, and the median cubital vein is a connecting vein between the cephalic and basilic veins. Therefore, all three veins can be accessed when drawing blood from the antecubital space. Choices A, B, and C are incorrect because each of these veins individually can be found in the antecubital space.
3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
- A. Angina at rest
- B. Thrombus formation
- C. Dizziness
- D. Falling blood pressure
Correct answer: B
Rationale: Thrombus formation is a critical complication of cardiac catheterization that the nurse should monitor for in the initial 24 hours after the procedure. A thrombus can form in the blood vessels, obstructing blood flow and potentially leading to serious consequences such as embolism or organ ischemia. While angina at rest, dizziness, and falling blood pressure are potential complications following cardiac catheterization, they are not typically associated with the immediate post-procedural period. Monitoring for thrombus formation is essential to ensure early detection and intervention, which can prevent serious complications.
4. A patient works with a nurse to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action?
- A. Remain silent.
- B. Educate the patient that the outcome is not realistic.
- C. Explore with the patient possible consequences of the outcome.
- D. Formulate an appropriate outcome without the patient's input.
Correct answer: C
Rationale: In this scenario, the nurse should collaborate with the patient rather than impose personal opinions. While the nurse should respect the patient's autonomy, they also have a duty to provide guidance. By exploring possible consequences of the suggested outcome with the patient, the nurse can facilitate a discussion that helps the patient make an informed decision. This approach respects the patient's input while ensuring their well-being. Remaining silent (Choice A) may not address the issue, educating the patient unilaterally (Choice B) may be perceived as dismissive, and formulating an outcome without patient input (Choice D) disregards the patient's autonomy and preferences.
5. When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?
- A. When the infant is sleeping
- B. At the end of the examination
- C. Before auscultation of the thorax
- D. At about the middle of the examination
Correct answer: B
Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.
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