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. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?
- A. "At least two (2) full meals a day are eaten."?
- B. "We go to a group discussion every week at our community center."?
- C. "We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?
- D. "The medication is not a problem to have taken three (3) times a day."?
Correct answer: C
Rationale: The correct answer is, '"We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?' Ensuring the safety of a client with Alzheimer's disease is crucial in home care. Installing safety features like bars in the bathroom and alarms on doors help prevent accidents and injuries. This contributes to creating a safe environment that promotes independence and autonomy for the client. Choices A, B, and D are incorrect because while they are important aspects of care, ensuring safety in the home environment takes precedence in caring for a client with Alzheimer's disease.
3. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?
- A. Client will be able to turn self by day 3
- B. Skin will remain intact and without redness during hospital stay
- C. Client will state pain relieved within 30 minutes after medication
- D. Pressure will be prevented by repositioning client every 2 hours
Correct answer: B
Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.
4. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
- A. Document the seizure
- B. Perform neurologic checks
- C. Take the patient's vital signs
- D. Restrain the patient for protection
Correct answer: C
Rationale: After a patient with migraine headaches has a seizure, it is important to assess their vital signs to monitor their condition. This task can be safely delegated to a nursing assistant as it falls within their scope of practice. Documenting the seizure and performing neurologic checks require a higher level of training and should be done by a nurse or healthcare provider. Restraint should never be used as a first-line intervention after a seizure unless there is an immediate threat to the patient's safety, and it should be done following proper protocols and with appropriate training.
5. To collect timely, specific information, the nurse is most likely to ask which of the following questions?
- A. Would you describe what you are feeling?
- B. How are you today?
- C. What would you like to talk about?
- D. Where does it hurt?
Correct answer: A
Rationale: The correct answer is, 'Would you describe what you are feeling?' This open-ended question prompts the patient to provide subjective data, offering specific information about their current health status and human responses. This information can help identify actual or potential health issues. Choices B and C are more likely to yield general, nonspecific information. Choice D may lead to a brief response or nonverbal indication of pain location. A more effective approach to gather specific information about pain would be to ask, 'Can you describe any pain you are experiencing?'
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