a registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department which of these clients should the charge n

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

A. A middle-aged client who says, "I took too many diet pills"? and "my heart feels like it is racing out of my chest."?
B. A young adult who says, "I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?"?
C. An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 11.
D. An elderly client who reports having taken a "large crack hit"? 10 minutes prior to walking into the emergency room.

Correct answer: C

Rationale: When assigning a floated nurse from another unit to a client in the emergency department, the goal is to choose a patient with minimal anticipated immediate complications. In this scenario, the adolescent with terminal cancer who has been on pain medications and presents with pinpoint pupils and a relaxed respiratory rate of 11 is the most stable option. These assessment findings indicate opioid toxicity, which, while serious, has the least risk of immediate complications compared to the other clients. Choice A involves a middle-aged client experiencing symptoms of possible cardiac issues due to diet pill overdose, which requires urgent intervention. Choice B presents a young adult with concerning symptoms of potential psychosis or substance withdrawal, requiring immediate attention. Choice D involves an elderly client who recently used crack, posing a high-risk situation that requires prompt evaluation and intervention. Therefore, the correct choice is the adolescent with opioid toxicity, as this client has the least immediate risk of complications among the options provided.

2. When reviewing the demographics of ethnic groups in the United States, which group does the nurse recall as the largest and fastest-growing population?

A. Asian
B. Hispanic
C. American Indian
D. African American/Black

Correct answer: B

Rationale: The correct answer is 'Hispanic.' Hispanics are the largest and fastest-growing population in the United States. While African Americans/Blacks, Asians, American Indians, and other groups are significant, Hispanics currently represent the largest demographic group. African American/Black, Asian, and American Indian populations are substantial but not as large or fast-growing as the Hispanic population. Therefore, Hispanic is the most appropriate choice in this scenario.

3. A client with expressive aphasia is pointing wildly at the bath water but unable to speak. Which response from the nurse is most appropriate?

A. Is something wrong with the bath water?
B. Just calm down, we'll finish your bath soon.
C. Are you trying to tell me something?
D. Shall I turn on the television?

Correct answer: A

Rationale: A client with expressive aphasia faces difficulty expressing themselves verbally but can understand others. In this scenario, the client's gestures indicate a communication attempt. The nurse's best response is to directly address the potential issue the client is indicating, which is the bath water. Option A acknowledges the client's non-verbal communication and seeks to address their concern. Choices B, C, and D do not directly address the client's attempt to communicate about the bath water, which is the focal point of the interaction.

4. What is the primary route of transmission of MRSA?

A. Shared needles
B. Hands of healthcare workers
C. Items in the healthcare environment
D. Blood transfusions

Correct answer: B

Rationale: The correct answer is 'Hands of healthcare workers.' MRSA is primarily transmitted via the unwashed hands of healthcare workers who can carry the Staphylococcus aureus bacterium from one patient to another. Shared needles, items in the healthcare environment, and blood transfusions are not the main routes of transmission for MRSA. Shared needles can transmit bloodborne pathogens, items in the healthcare environment can harbor bacteria but are not the primary mode for MRSA, and blood transfusions are not a common route for MRSA transmission.

5. Surgical asepsis is being performed when:

A. wiping down exam tables with bleach
B. sterilizing instruments
C. changing table paper
D. wearing gloves when performing injections

Correct answer: B

Rationale: Surgical asepsis refers to the process of maintaining a sterile environment to prevent the introduction of pathogens to a patient's body. Sterilizing instruments is a crucial aspect of surgical asepsis as it ensures that the instruments used during procedures are free from microorganisms that could cause infections. Wiping down exam tables with bleach may help in cleaning and disinfecting surfaces but does not pertain directly to maintaining a sterile field. Changing table paper is important for cleanliness and infection control but is not specifically related to surgical asepsis. Wearing gloves when performing injections is important for standard precautions and preventing the spread of infection but does not encompass the concept of surgical asepsis, which focuses on maintaining a sterile field during invasive procedures.