NCLEX-RN
NCLEX RN Predictor Exam
1. Efforts by healthcare facilities to reduce the incidence of hospital-acquired infections (HAIs) include an awareness of which of the following?
- A. The CDC requires all states to report HAI rates from each hospital.
- B. Ensure that the restraints are tied to the side rails.
- C. The gastrointestinal tract is a common site for HAIs.
- D. Joint Commission considers death or serious injury from HAIs a sentinel event.
Correct answer: D
Rationale: Efforts to reduce hospital-acquired infections (HAIs) involve being aware that the Joint Commission considers death or serious injury resulting from HAIs a sentinel event, which must be reported. While more than 20 states require reporting of HAI rates to the CDC, it is not a nationwide CDC requirement. The gastrointestinal tract is not a specific common site for HAIs; rather, bacteria are the primary cause. Ensuring restraints are properly secured is important for patient safety but not directly related to reducing HAIs.
2. 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.
3. In the term 'Hemoglobin,' the suffix '-globin' means:
- A. Protein
- B. Iron
- C. Metal
- D. Blood
Correct answer: A
Rationale: The suffix '-globin' in the term 'Hemoglobin' specifically refers to a protein. Hemoglobin is a protein found in red blood cells that carries oxygen. Choice B, 'Iron,' is incorrect as iron is a mineral component of hemoglobin but not the meaning of the suffix. Choice C, 'Metal,' is too broad and not specific to the meaning of the suffix in this context. Choice D, 'Blood,' is incorrect as it refers to the overall term 'Hemoglobin' rather than the specific meaning of the suffix '-globin.' Therefore, the correct answer is A: 'Protein.'
4. When measuring a patient's body temperature, what factor should be considered that can influence the temperature?
- A. Constipation
- B. Diurnal cycle
- C. Nocturnal cycle
- D. Patient's emotional state
Correct answer: B
Rationale: When measuring body temperature, it is essential to consider factors that can influence it. The diurnal cycle, which refers to the body's natural temperature variations throughout a 24-hour period, can impact body temperature readings. Factors like exercise, age, and environment can also affect body temperature. Constipation does not directly influence body temperature. The 'nocturnal cycle' is not a recognized term in relation to body temperature. While a patient's emotional state can affect vital signs, it is not a primary factor in influencing body temperature measurements.
5. Which technique is correct when assessing the radial pulse of a patient?
- A. Palpate for 1 minute if the rhythm is irregular.
- B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
- C. Palpate for 2 full minutes to detect any variation in amplitude.
- D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.
Correct answer: A
Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.
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