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: B
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. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?
- A. ''This action of my lips helps to keep my airway open.''
- B. ''I can expel more air when I pucker up my lips to breathe out.''
- C. ''My mouth doesn't get as dry when I breathe with pursed lips.''
- D. ''By prolonging breathing out with pursed lips, the smaller areas in my lungs don't collapse.''
Correct answer: D
Rationale: The correct answer is D. Clients with chronic obstructive pulmonary disease have difficulty exhaling fully due to the weak alveolar walls from the disease process. Pursed-lip breathing helps prevent alveolar collapse by maintaining positive pressure in the airways during exhalation. This is the major reason for using pursed-lip breathing in individuals with chronic obstructive lung disease. Choices A, B, and C are incorrect because they do not directly address the main purpose of pursed-lip breathing, which is to prevent alveolar collapse and improve exhalation in these patients.
3. When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?
- A. The body temperature of the older adult is lower than that of a younger adult.
- B. An older adult's body temperature is approximately the same as that of a young child.
- C. Body temperature varies based on the type of thermometer used.
- D. In older adults, body temperature can fluctuate widely due to less effective heat control mechanisms.
Correct answer: A
Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2°C. Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child. Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used. Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.
4. Which gland of the endocrine system secretes a hormone that assists with the sleep/wake cycle?
- A. Pituitary
- B. Pineal
- C. Pancreas
- D. Hypothalamus
Correct answer: B
Rationale: The correct answer is the Pineal gland. The Pineal gland, located in the brain, secretes melatonin, which plays a crucial role in regulating the sleep/wake cycle in response to exposure to light. The Pituitary gland (Choice A) secretes various hormones but not specifically related to the sleep/wake cycle. The Pancreas (Choice C) secretes insulin and digestive enzymes, not hormones related to the sleep/wake cycle. The Hypothalamus (Choice D) is involved in regulating many bodily functions, including hormone secretion, but it does not directly secrete the hormone that regulates the sleep/wake cycle.
5. Which of the following scenarios provides an example of a healthcare professional overcoming a barrier to communication?
- A. A healthcare professional uses a visual aid to explain how to conduct a fingerstick glucose test to a patient with visual impairment.
- B. A healthcare professional writes down instructions for a patient who is hearing impaired.
- C. A healthcare professional raises their voice when speaking to a patient who does not speak English.
- D. A healthcare professional uses medical jargon while conversing with a minor.
Correct answer: B
Rationale: Overcoming barriers to communication in healthcare involves utilizing methods of communication that are accessible and understandable to the recipient. In the scenario provided, writing down instructions for a patient who is hearing impaired is an effective way to ensure clear communication and overcome the obstacle of hearing impairment. This method allows the patient to visually comprehend the information provided. Choice A is incorrect because using a visual aid for a visually impaired patient, not a hearing-impaired patient, would be more appropriate. Choice C is incorrect as raising one's voice does not address the language barrier effectively and may not enhance understanding. Choice D is incorrect as using complex medical terms with a minor may lead to confusion and hinder effective communication.
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