NCLEX NCLEX-RN
NCLEX RN Predictor Exam
1. Digestion, elimination, and ___________ are the three functions of the digestive system.
- A. constriction
- B. relaxation
- C. absorption
- D. peristalsis
Correct answer: C: absorption
Rationale: The correct answer is 'absorption.' The three main functions of the digestive system are digestion, absorption, and elimination. Absorption refers to the process of absorbing nutrients and other substances from the digested food into the bloodstream. Choices A, B, and D are incorrect: Constriction is not a primary function of the digestive system, relaxation is not a distinct function in this context, and peristalsis is a muscular movement that aids in digestion but is not one of the three main functions of the digestive system.
2. The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should the nurse provide to ensure the optimal benefits from the drug?
- A. Fill your lungs with air through your mouth and then compress the inhaler.
- B. Compress the inhaler while slowly breathing in through your mouth.
- C. Compress the inhaler while inhaling quickly through your nose.
- D. Exhale completely after compressing the inhaler and then inhale.
Correct answer: Compress the inhaler while slowly breathing in through your mouth.
Rationale: To ensure optimal benefits from a metered-dose inhaler, the client should be instructed to compress the inhaler while slowly breathing in through the mouth. This technique facilitates the medication to reach deep into the lungs, allowing for an optimal bronchodilation effect. Option B is correct as it promotes the proper coordination of inhaler compression and inhalation, ensuring effective drug delivery. Options A, C, and D are incorrect as they do not support deep lung penetration of the medication, which is essential for its effectiveness in treating respiratory conditions.
3. Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?
- A. Vest restraints should be used because they are the least restrictive type.
- B. Restraints should be used for 48 hours in non-psychiatric patients.
- C. Restraints should be applied to prevent wandering behavior.
- D. Alternative measures must be attempted first.
Correct answer: Alternative measures must be attempted first.
Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.
4. A 30-year-old woman is scheduled for a total abdominal hysterectomy due to noninvasive endometrial cancer. The nurse anticipates the client may have difficulty adjusting emotionally to this type of surgery. Which concern would be the cause of this anticipated difficulty?
- A. Change in femininity
- B. Body image changes
- C. Diminished sexual desire
- D. Slow recovery
Correct answer: Change in femininity
Rationale: The correct answer is 'Change in femininity.' The removal of the uterus can lead to changes in how some women perceive themselves sexually as it is a reproductive organ. In this young client, there may be heightened feelings of loss of femininity and reproductive potential. Body image changes could occur but are more likely with surgeries involving obvious external changes. Diminished sexual desire is unlikely in a premenopausal woman unless she has specific concerns. Slow recovery is not expected in an otherwise healthy 30-year-old woman undergoing this surgery.
5. Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?
- A. Manage secretions by providing suction on a regular basis
- B. Cleanse the site daily with a mixture of povidone-iodine and water
- C. Avoid using tube ties to secure the tube
- D. None of the above
Correct answer: Manage secretions by providing suction on a regular basis
Rationale: Excess secretions from the tracheostomy tube can collect near the stomal opening and cause skin breakdown. Management of secretions through regular suctioning will keep the area clean and dry, minimizing skin irritation. Choice B, cleansing the site daily with povidone-iodine and water, is incorrect as it may lead to skin irritation due to the harshness of povidone-iodine. Choice C, avoiding tube ties to secure the tube, is also incorrect as securing the tube is essential for stability. Choice D, 'None of the above,' is incorrect as managing secretions through suctioning is crucial in preventing skin irritation.
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