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. In which of these patients would rectal temperatures be measured?
- A. Older adult
- B. Critically ill patient
- C. School-age child
- D. Patient receiving oxygen via nasal cannula
Correct answer: B
Rationale: Rectal temperature measurement is preferred in situations where other routes are impractical or when the most accurate measure is necessary, such as in critically ill patients. The rectal route may be chosen due to its reliability in such cases. For older adults, school-age children, and patients receiving oxygen via nasal cannula, rectal temperature measurement is not typically indicated. Other routes like oral, tympanic, or axillary measurements are more commonly used in these populations due to comfort, convenience, and non-invasive nature.
3. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?
- A. Help client into the chair more quickly
- B. Document client's vital signs taken just prior to moving the client
- C. Help client back to bed immediately
- D. Observe client's skin color and take another set of vital signs
Correct answer: D
Rationale: In this scenario, the nurse has observed concerning signs in the client during the transfer process. The appropriate action for reassessment would be to observe the client's skin color and take another set of vital signs. This will provide essential data to evaluate the client's condition more accurately. Options A, B, and C are interventions that do not address the need for reassessment. Moving the client more quickly, documenting previous vital signs, or returning the client to bed do not directly address the need to reassess the client's current condition.
4. When a nurse's hand comes in contact with a client's blood after providing wound care, what is the next action the nurse should take?
- A. Use an alcohol-based hand sanitizer to disinfect the hands
- B. Wash hands with soap and water using appropriate technique
- C. Notify the appropriate personnel about the exposure to client's blood
- D. Sample some of the client's blood to determine the presence of diseases
Correct answer: B
Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.
5. Which of the following questions is considered open-ended?
- A. What time did you last take your medications?
- B. Are you feeling okay right now?
- C. Please describe your symptoms.
- D. What day are you available for a follow-up appointment?
Correct answer: C
Rationale: The correct answer is 'Please describe your symptoms.' This question is considered open-ended because it encourages the respondent to provide a detailed and descriptive answer, fostering a more elaborate response. Open-ended questions are designed to prompt thoughtful and detailed responses. Choice A is a closed-ended question since it seeks a specific time for the medication intake. Choice B is also closed-ended as it can be answered with a simple 'yes' or 'no,' limiting the response. Choice D is closed-ended as it requests a specific day for the follow-up appointment, restricting the range of possible responses.
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