NCLEX-RN
NCLEX RN Predictor Exam
1. In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Universal precautions
Correct answer: A
Rationale: Rubella is an illness transmitted by large-particle droplets, so the nurse should implement droplet precautions in addition to standard precautions. Airborne precautions are used for diseases spread through small particles in the air, such as tuberculosis, varicella, and rubeola. Contact precautions are utilized for diseases transmitted by direct contact with the patient or their environment. Universal precautions and body substance isolations are part of the CDC's standard precautions recommendations, but do not specifically address the transmission route of rubella.
2. What term is used to refer to generalized wasting of body tissues and malnutrition?
- A. Entropion
- B. Confabulation
- C. Induration
- D. Cachexia
Correct answer: D
Rationale: Cachexia is the correct term used to describe the generalized wasting of body tissues, ill health, and malnutrition associated with some chronic diseases. It involves a loss of fat tissue to protect the bones and joints. Clients with cachexia are at risk of pressure ulcers and other complications due to malnutrition and poor health. Entropion refers to an eyelid condition, confabulation is a memory disturbance, and induration is the abnormal hardening of a part of the body.
3. An Asian-American woman is experiencing diarrhea, which is believed to be "cold"? or "yin."? What should the nurse recognize that the woman may likely try to treat it?
- A. Foods that are "hot"? or "yang"?
- B. Readings and Eastern medicine meditations
- C. High doses of medicines believed to be "cold"?
- D. No treatment because diarrhea is an expected part of life.
Correct answer: A
Rationale: In this scenario, the Asian-American woman is believed to be experiencing diarrhea due to a "cold"? or "yin"? imbalance. According to the yin/yang theory, yang represents heat and yin represents cold. Therefore, to balance the cold nature of the diarrhea, the woman may try to treat it by consuming foods that are considered "hot"? or "yang"?. This aligns with the concept that cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. Choices B, C, and D do not align with the yin/yang theory and are not relevant to addressing the imbalance associated with the cold nature of the diarrhea.
4. A healthcare professional is preparing to administer a dose of platelets to a client. Which of the following actions must the healthcare professional perform before giving the platelets?
- A. Start an IV of 0.9% Normal Saline to administer with the platelets
- B. Ensure the container with the platelets is intact and not damaged
- C. Verify the client's identity using two unique identifiers
- D. Check the client's chart to ensure no contraindications to platelet transfusion
Correct answer: B
Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.
5. The healthcare professional is preparing to auscultate the abdomen. How should they proceed?
- A. Warm the endpiece of the stethoscope by rubbing it between their hands.
- B. Ensure the patient is adequately covered and comfortable during the examination.
- C. Ensure that the diaphragm side of the stethoscope is in use.
- D. Check the room temperature and offer blankets to the patient if needed.
Correct answer: D
Rationale: When preparing to auscultate the abdomen, it is important to ensure the patient's comfort. The room should be warm to prevent shivering, which can interfere with sound clarity. Offering blankets to the patient if they feel cold helps maintain their comfort during the examination. The endpiece of the stethoscope should be warmed by rubbing it between the examiner's hands, not by placing it in warm water. It is important to use the diaphragm, not the bell, of the stethoscope to auscultate for bowel sounds. Therefore, choice D is the correct answer, as it addresses the patient's comfort and the room temperature, which are essential for a successful abdominal auscultation.
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