if a sequence of repeated weights is necessary then the nurse should attempt to weigh the patient at approximately the same time of day and with the s

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. When a sequence of repeated weights is necessary, the healthcare provider should aim to weigh the patient at the same time of day and with consistent clothing. Using a standardized balance or electronic standing scale is recommended for accurate measurements. The patient should remove shoes and heavy outer clothing. It is not required for the patient to always be weighed in undergarments. What is the most appropriate indicator of the patient's overall well-being?

A. General health
B. Genetic makeup
C. Nutritional status
D. Activity and exercise patterns

Correct answer: General health

Rationale: Weight measurements are essential to assess general health, particularly in monitoring growth patterns. Height and weight recordings are crucial indicators of overall well-being, reflecting the individual's health status. Genetic makeup does not change with weight fluctuations, making it an inappropriate indicator. Nutritional status and activity levels can influence weight but are not as comprehensive as general health in reflecting overall well-being.

2. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

A. UAP splint the patient's chest during coughing.
B. UAP assist the patient to ambulate to the bathroom.
C. UAP help the patient to a bedside chair for meals.
D. UAP lower the head of the patient's bed to 15 degrees.

Correct answer: UAP lower the head of the patient's bed to 15 degrees.

Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.

3. Which of the following items of subjective client data would be documented in the medical record by the nurse?

A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feels nauseated

Correct answer: Client feels nauseated

Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.

4. A healthcare provider attempts to plug in a sequential compression device when they notice a tingling sensation in their hands while touching the cord. What is the next action of the healthcare provider?

A. Attempt to plug the device into a different outlet
B. Inspect the cord for damage; if none is present, continue to use the device
C. Discontinue the device and send it to the maintenance department for inspection
D. Notify the supervisor that the unit is at risk of an electrical fire

Correct answer: Discontinue the device and send it to the maintenance department for inspection

Rationale: Feeling a tingling sensation when touching an electrical cord is a warning sign that the device may be malfunctioning. This sensation indicates a potential electrical current leak, which could pose a risk of harm. The correct action is to immediately discontinue the use of the device and send it to the maintenance department for inspection. Continuing to use the device without addressing the issue could lead to electric shock or fire hazards. Trying to plug the device into a different outlet does not address the underlying problem of potential device malfunction. Notifying the supervisor about the risk of an electrical fire is important, but the immediate action should be to stop using the device and have it inspected by maintenance professionals. Therefore, the best course of action is to discontinue the device and ensure it is checked thoroughly before further use.

5. Which of the following is NOT an acceptable abbreviation?

A. D/C
B. tid
C. bid
D. qid

Correct answer: A: D/C

Rationale: The correct answer is A: D/C. D/C is not an acceptable abbreviation as it can be easily confused with both 'discharge' and 'discontinue.' The abbreviations 'tid' (three times a day), 'bid' (twice a day), and 'qid' (four times a day) are commonly used in medical contexts to indicate dosing frequencies and are widely accepted in healthcare settings.