NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?
- A. 240 cc
- B. 120 cc
- C. 8 cc
- D. 0 cc because Italian ice is not a fluid
Correct answer: A
Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.
2. Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.
- A. Client and Family
- B. Other nursing staff on the unit
- C. Security department
- D. Hospital administration
Correct answer: B
Rationale: Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.
3. Surgical asepsis is being performed when:
- A. wiping down exam tables with bleach
- B. sterilizing instruments
- C. changing table paper
- D. wearing gloves when performing injections
Correct answer: B
Rationale: Surgical asepsis refers to the process of maintaining a sterile environment to prevent the introduction of pathogens to a patient's body. Sterilizing instruments is a crucial aspect of surgical asepsis as it ensures that the instruments used during procedures are free from microorganisms that could cause infections. Wiping down exam tables with bleach may help in cleaning and disinfecting surfaces but does not pertain directly to maintaining a sterile field. Changing table paper is important for cleanliness and infection control but is not specifically related to surgical asepsis. Wearing gloves when performing injections is important for standard precautions and preventing the spread of infection but does not encompass the concept of surgical asepsis, which focuses on maintaining a sterile field during invasive procedures.
4. Penny Thornton has had a stroke, or CVA, and is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be providing Penny with these assistive devices?
- A. A physical therapist
- B. A speech therapist
- C. A social worker
- D. An occupational therapist
Correct answer: D
Rationale: An occupational therapist is the healthcare professional responsible for assessing the needs of individuals, like Penny, regarding assistive devices that aid them in their daily activities. In this case, assistive devices for eating, such as weighted plates and specialized utensils, are crucial for helping Penny regain independence in feeding herself. Physical therapists focus more on mobility and movement, speech therapists on communication and swallowing disorders, and social workers on providing emotional and social support. Therefore, the correct choice is the occupational therapist as they specialize in activities of daily living and promoting independence.
5. What is the most important step that healthcare personnel can take to prevent the transmission of microorganisms in the hospital setting?
- A. Wear protective eyewear at all times.
- B. Wear gloves whenever in direct contact with patients.
- C. Wash hands before and after contact with each patient.
- D. Clean the stethoscope with an alcohol swab between patients.
Correct answer: C
Rationale: The most crucial step in preventing the transmission of microorganisms in the hospital setting is proper hand hygiene. Healthcare personnel should wash their hands thoroughly before and after each patient contact to reduce the risk of spreading infections. While cleaning the stethoscope with an alcohol swab between patients is recommended, it is secondary to hand hygiene. Wearing protective eyewear at all times is not necessary for routine patient care unless specifically indicated, and wearing gloves only when in direct contact with patients is important but not as critical as proper handwashing. Therefore, the correct answer is to wash hands before and after contact with each patient.
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