NCLEX NCLEX-RN
NCLEX RN Exam Prep
1. The nurse should wash from the ________________________ when washing a patient's eye area.
- A. outer canthus to the inner canthus
- B. inner canthus to the outer canthus
- C. internal nares to the external nares
- D. external nares to the internal nares
Correct answer: inner canthus to the outer canthus
Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.
2. An experienced healthcare professional instructs a new colleague on caring for a patient with dyspnea due to a pulmonary fungal infection. Which action by the new colleague indicates a need for further teaching?
- A. Listening to the patient's lung sounds several times during the shift
- B. Placing the patient in droplet precautions and in a private hospital room
- C. Increasing the oxygen flow rate to maintain oxygen saturation above 90%
- D. Monitoring the patient's serology results to identify the specific infecting organism
Correct answer: Placing the patient in droplet precautions and in a private hospital room
Rationale: The correct answer is placing the patient in droplet precautions and in a private hospital room. Fungal infections are not transmitted from person to person, so isolation procedures like droplet precautions are unnecessary. Listening to the patient's lung sounds, increasing the oxygen flow rate, and monitoring serology results are all appropriate actions in caring for a patient with dyspnea caused by a pulmonary fungal infection.
3. A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breastfeed the infants. Which of the following is based on sound rationale?
- A. Nursing will help contract the uterus and reduce your risk of bleeding.
- B. Breastfeeding twins will take too much energy after the hemorrhage.
- C. The blood transfusion may increase the risks to you and the babies.
- D. Lactation should be delayed until the 'real milk' is secreted.
Correct answer: Nursing will help contract the uterus and reduce your risk of bleeding.
Rationale: The correct answer is 'Nursing will help contract the uterus and reduce your risk of bleeding.' Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage. Choice B is incorrect because breastfeeding can actually help prevent further bleeding by promoting uterine contractions. Choice C is incorrect as the blood transfusion is aimed at restoring the client's blood volume and should not significantly impact the babies. Choice D is incorrect as lactation should not be delayed, as breastfeeding can provide numerous benefits to both the mother and infants, including aiding in the prevention of postpartum hemorrhage.
4. A client is being instructed on how to use crutches. Which of the following information should be included in the teaching?
- A. Place the majority of body weight on the axilla.
- B. Dry crutch tips with a paper towel if they become wet.
- C. Use the crutches for support to lift both feet simultaneously when ascending stairs.
- D. Both B and C.
Correct answer: Dry crutch tips with a paper towel if they become wet.
Rationale: When instructing a client on how to use crutches for ambulation, it is important to emphasize keeping the crutch tips dry to prevent slipping while bearing weight on them. Moisture on the crutch tips can lead to accidents. Therefore, the correct answer is to dry the crutch tips with a paper towel if they become wet. Choice A, placing the majority of body weight on the axilla, is incorrect as the weight should be borne through the hands, not the axilla, to avoid nerve damage. Choice C, using the crutches to lift both feet simultaneously when ascending stairs, is incorrect as the client should ascend stairs by placing weight on the unaffected leg first, followed by the crutches and then the affected leg. This method provides stability and safety during stair climbing.
5. Which action often triggers an episode of violence or aggression in a patient with a psychiatric diagnosis involving violent behavior?
- A. Obtaining a history
- B. Asking for input into care
- C. Enforcing rules
- D. Taking a walk
Correct answer: Enforcing rules
Rationale: Enforcing rules is often a trigger for patients with psychiatric diagnoses involving violent behavior. Limit-setting or denying patient demands can be perceived as control and intimidation, leading to aggressive responses. Nursing staff must respond calmly and professionally to prevent escalation. Avoiding such patients or matching their emotions can worsen the situation. Therefore, enforcing rules can provoke violent episodes in these patients.
Similar Questions
Access More Features
NCLEX Basic
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX Basic
- 5,000 Questions and answers
- Comprehensive NCLEX Coverage
- 90 days access @ $69.99