the hospital has sounded the call for a disaster drill on the evening shift which of these clients would the nurse put first on the list to be dischar

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse prioritize first on the list to be discharged in order to make a room available for a new admission?

A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.

Correct answer: A

Rationale: The best candidate for discharge during a need for emergency room availability is a stable patient with a chronic condition who is familiar with their care. In this scenario, the middle-aged client in option A, who has been ventilator dependent for over seven years and admitted with bacterial pneumonia five days ago, is most suitable for discharge. This client is likely stable and can continue medication therapy at home, making them the most appropriate choice for discharge at this time. Choice B should not be the priority for discharge as the young adult with diabetes mellitus Type 2 admitted with antibiotic-induced diarrhea 24 hours ago may need further monitoring and management of their condition. Choice C, the elderly client with multiple comorbidities and admitted with Stevens-Johnson syndrome on the same day, is not a suitable candidate for immediate discharge as they may require ongoing medical attention and observation. Choice D, the adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago, should not be discharged first as acute cellulitis may require continued treatment and monitoring, especially in the context of a positive HIV status.

2. What is the purpose of MSDS sheets?

A. Contain the ordering information for each piece of equipment in the office.
B. Are required by OSHA to be accessible to all employees of the office.
C. Can be used to treat patients who have been injured in equipment accidents.
D. None of the above.

Correct answer: B

Rationale: MSDS sheets, also known as Materials Safety Data Sheets, are essential documents that provide detailed information about chemicals used in the workplace. They are required by OSHA to be easily accessible to all employees to ensure they have the necessary information to handle chemicals safely. MSDS sheets do not contain ordering information for equipment in the office (Choice A) or serve as a treatment guide for injured patients (Choice C). Therefore, the correct answer is that MSDS sheets are required by OSHA to be accessible to all employees of the office.

3. The nurse is unable to palpate the right radial pulse on a patient. What would the nurse do next?

A. Auscultate over the area with a fetoscope.
B. Use a goniometer to measure the pulsations.
C. Use a Doppler device to check for pulsations over the area.
D. Check for the presence of pulsations with a stethoscope.

Correct answer: C

Rationale: When a nurse is unable to palpate a radial pulse, the next step is to use a Doppler device to check for pulsations over the area. Doppler devices are specifically designed to augment pulse or blood pressure measurements. Auscultating with a fetoscope is used to listen to fetal heart tones and is not relevant in this scenario. Goniometers are used to measure joint range of motion and are not used to assess pulses. Stethoscopes are primarily used to auscultate breath, bowel, and heart sounds, not to check for pulsations in peripheral pulses. Therefore, the correct course of action when unable to palpate a pulse is to utilize a Doppler device to assess for pulsations in the radial pulse area.

4. A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?

A. Allow 5 minutes for the student to relax and rest before checking their vital signs.
B. Check the blood pressure in both arms, expecting a difference in the readings due to the recent exercise.
C. Immediately monitor the student's vital signs upon arrival at the clinic and then 5 minutes later, recording any differences.
D. Check the student's blood pressure in the supine position to provide a more accurate reading and allow the student to relax at the same time.

Correct answer: A

Rationale: To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.

5. Which of the following sets of word parts means 'Pain'?

A. dynia and -algia
B. a- and an
C. ia and -ac
D. pathy and -osis

Correct answer: A

Rationale: The correct answer is 'dynia and -algia.' The word parts 'dynia' and '-algia' specifically relate to pain. 'Dynia' refers to pain, and '-algia' also denotes pain. Therefore, when combined, they form the meaning 'pain.' Choices B, C, and D are incorrect because 'a-' and 'an' do not relate to pain, 'ia' and '-ac' do not specifically convey pain, and 'pathy' and '-osis' are not word parts that directly signify pain.