NCLEX-RN
NCLEX RN Exam Prep
1. The supervising RN asks you to bring the unit's collected lab specimens to the lab 'stat'. You should ______________.
- A. not decline this task because nurses do not handle 'stats'.
- B. run this errand as promptly as possible
- C. run this errand immediately and without delay
- D. Complete this task before the end of your shift or after your lunch.
Correct answer: C
Rationale: In healthcare settings, 'stat' is commonly used to indicate that something should be done immediately and without any delay. It is a critical term used to prioritize urgent tasks. Nurses are responsible for various tasks, including handling urgent requests such as transporting lab specimens promptly. Option A is incorrect as nurses can handle urgent tasks like 'stats'. Option B is not as specific as option C, which clearly emphasizes the need for immediate action. Option D is incorrect as it suggests delaying the task until later, which goes against the urgency implied by the term 'stat'.
2. What is the most effective step in hand washing?
- A. Using friction to remove potential pathogens.
- B. Using hospital-grade soap.
- C. Moisturizing the hands after washing to prevent cracking.
- D. Washing hands with soap for at least 15 seconds.
Correct answer: A
Rationale: The most effective step in hand washing is using friction to remove potential pathogens. While using soap, moisturizing hands, and washing for a sufficient duration are important aspects of hand hygiene, the mechanical action of rubbing hands together with friction is crucial in dislodging and removing dirt, debris, and potential pathogens. Hospital-grade soap may be beneficial, but the physical act of friction is key to effective hand washing. Moisturizing after washing is important for skin health but not the most effective step in the hand washing process. Simply washing hands for a specific duration, such as 15 seconds, without proper friction may not effectively remove contaminants. Therefore, using friction for thorough cleaning is the most crucial step in hand washing.
3. During the general survey, what action is a component of the assessment?
- A. Observing the patient's body stature and nutritional status
- B. Interpreting the subjective information reported by the patient
- C. Measuring the patient's temperature, pulse, respirations, and blood pressure
- D. Observing specific body systems during the physical assessment
Correct answer: A
Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.
4. A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?
- A. Rigor mortis
- B. Postmortem decomposition
- C. Algor mortis
- D. Livor mortis
Correct answer: C
Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.
5. Should standard precautions be used when providing post mortem care to a patient who has died from a massive heart attack and had no other diseases, illnesses, or infections?
- A. Yes, because the patient must be treated with respect
- B. Yes, you still must use standard precautions
- C. No, because the patient had no infections
- D. No, because this is not respectful
Correct answer: B
Rationale: Yes, you must still use standard precautions when providing post mortem care, regardless of the patient's medical history. Standard precautions are essential to prevent the transmission of potential infectious agents and protect both the healthcare provider and others from exposure. Even if the patient did not have known infections, it is crucial to maintain a safe environment and uphold professional standards of care. Choice A is incorrect as using standard precautions is primarily for infection control rather than solely for respect. Choices C and D are incorrect as the absence of infections or the notion of respect does not negate the need for standard precautions in post mortem care.
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