NCLEX-RN
NCLEX RN Predictor Exam
1. The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or healthcare providers, the nurse emphasizes interventions that do which of the following? (Berman & Snyder, 2012, p. 713)
- A. Eliminate the reservoir
- B. Block the portal of exit from the reservoir
- C. Block the portal of entry into the host
- D. Decrease the susceptibility of the host
Correct answer: B
Rationale: To prevent the spread of infection from a chronic carrier, the nurse should focus on blocking the portal of exit from the reservoir, which is the carrier person. By preventing the movement of the organism from the reservoir, the infection can be contained. Eliminating the reservoir is not feasible in this case as the carrier is a chronic carrier. Blocking the portal of entry into the host or decreasing the susceptibility of the host would only impact individual prevention and not the spread from the carrier to others.
2. Which of the following is an example of physical abuse?
- A. A slap to the person's hand
- B. Threatening the person
- C. Ignoring and isolating a person
- D. Leaving a patient soiled for hours
Correct answer: A
Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.
3. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?
- A. Assessing the patient for jaundice
- B. Providing oral hygiene after a meal
- C. Palpating the abdomen for distention
- D. Assisting the patient to choose the diet
Correct answer: B
Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.
4. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?
- A. No, this temperature is within normal limits.
- B. No, this temperature is normally hyperthermic.
- C. Yes, this temperature is highly hyperthermic.
- D. Yes, this temperature is highly hypothermic.
Correct answer: A
Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.
5. A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?
- A. A history of hepatitis C five years previously
- B. Cholecystitis requiring cholecystectomy one year previously
- C. Asymptomatic diverticulosis
- D. Crohn's disease in remission
Correct answer: A
Rationale: A history of hepatitis C five years previously would prevent a donor from donating blood for transfusion. Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis requiring cholecystectomy one year previously, asymptomatic diverticulosis, and Crohn's disease in remission are not contraindications for blood donation as they do not pose a risk of transmitting infections to the recipient.
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