NCLEX-RN
NCLEX RN Exam Prep
1. One major difference between long term care and respite centers is the fact that long term care facilities:
- A. provide both physical and emotional care on an ongoing basis, while respite centers offer only temporary services.
- B. provide care for residents on a long-term basis, while respite centers offer only outpatient services.
- C. provide care for residents on a long-term basis, while respite centers offer only temporary services.
- D. There is no difference. Long-term care and respite care are the same.
Correct answer: C
Rationale: The major difference between long-term care and respite centers is that long-term care facilities provide both physical and emotional care on an ongoing, long-term basis. This continuous care is essential for residents who require extended assistance. In contrast, respite centers offer temporary services, providing similar care but for a short-term duration. These short-term services are designed to give family caregivers a break from their daily responsibilities. Choice A is incorrect because both long-term care and respite centers can offer both physical and emotional care, but the key distinction lies in the duration of care provided. Choice B is incorrect as respite centers do not typically offer outpatient services, and the focus is on temporary relief rather than long-term care. Choice D is incorrect as the question clearly highlights a major difference between long-term care and respite centers.
2. A nurse is preparing to change a client's dressing for a burn wound on his foot. Which of the following interventions is appropriate for this process?
- A. Wash the wound with cleanser, rinse, and pat dry
- B. Bind the wound tightly, secure with tape, and elevate the foot
- C. Contact the physician after the dressing change is complete
- D. Provide analgesics for the client after the procedure
Correct answer: A
Rationale: When changing the dressing for a burn wound, it is essential to follow appropriate interventions to prevent infection, reduce pain, and support healing. In this scenario, after removing the old dressing, it is crucial to wash the wound gently with a suitable cleanser, rinse the area thoroughly, and then pat it dry. This process helps in maintaining cleanliness, reducing the risk of infection, and providing a conducive environment for healing. Binding the wound tightly (Choice B) can impede circulation and delay healing. Contacting the physician after the dressing change (Choice C) may be necessary in specific situations but is not a standard step in routine dressing changes. Providing analgesics after the procedure (Choice D) is important for pain management but is not directly related to the dressing change itself.
3. When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment?
- A. Goggles
- B. Gown
- C. Surgical mask
- D. Clean gloves
Correct answer: A
Rationale: Goggles may be reused unless they are overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off. Gowns are at high risk for contamination and should be used only once and then discarded or washed. Surgical masks and gloves should never be washed or reused. Goggles provide eye protection from splashes and should be cleaned and disinfected after each use to ensure proper protection.
4. During an examination, a nurse notices a draining ulceration on a patient's lower leg. What is the most appropriate action in this situation?
- A. Wash hands and then contact the physician.
- B. Continue to examine the ulceration and then wash hands.
- C. Wash hands, put on gloves, and continue with the examination of the ulceration.
- D. Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last.
Correct answer: C
Rationale: In this scenario, the most appropriate action is to wash hands, put on gloves, and then continue examining the ulceration. Wearing gloves is crucial when there is a possibility of contact with body fluids, as in the case of a draining ulceration. Contacting the physician is not necessary at this point; the immediate focus should be on proper infection control by washing hands and wearing gloves. Changing the order of the examination is not recommended as it is important to follow a systematic approach to avoid missing any crucial assessments.
5. The healthcare professional is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?
- A. Turgor
- B. Texture
- C. Density
- D. Consistency
Correct answer: C
Rationale: Percussion is a technique used to assess the density of underlying organs by producing sounds that help determine their location and size. Turgor, texture, and consistency are primarily assessed through palpation, not percussion. Turgor refers to skin elasticity, texture pertains to the feel of the tissue surface, and consistency relates to the firmness or resistance of the tissue.
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