NCLEX-RN
NCLEX RN Predictor Exam
1. When caring for a patient with latex allergy, the healthcare provider creates a latex-safe environment by doing which of the following?
- A. Carefully cleaning the wall-mounted blood pressure device before using it.
- B. Donning latex gloves outside the room to limit powder dispersal.
- C. Using a latex-free pharmacy protocol.
- D. Placing the patient in a semi-private room.
Correct answer: C
Rationale: Creating a latex-safe environment for a patient with latex allergy is crucial to prevent allergic reactions. Using a latex-free pharmacy protocol is essential as it ensures that medications and supplies provided to the patient are free of latex components. Cleaning a wall-mounted blood pressure device may not be sufficient as the device itself may contain latex parts that can trigger an allergic reaction. Donning latex gloves, even outside the room, is not recommended as powder dispersal can cause issues; only non-latex gloves should be used in a latex-safe environment. Placing the patient in a semi-private room does not directly address the need to eliminate latex exposure from medical supplies and equipment, which is better achieved through a latex-free pharmacy protocol.
2. When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?
- A. After menopause, blood pressure readings in women are usually higher than those taken in men.
- B. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
- C. Blood pressure measurements in people who are overweight are usually higher than those of people who are at a normal weight.
- D. A teenager's blood pressure reading may be lower than that of an adult.
Correct answer: B
Rationale: When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.
3. Which is the most effective action for controlling the spread of infection?
- A. Thorough hand hygiene
- B. Wearing gloves and masks when providing direct client care
- C. Implementing appropriate isolation precautions
- D. Administering broad-spectrum prophylactic antibiotics
Correct answer: A
Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.
4. The acronym FAST is used to help responders remember the steps to recognizing which of the following conditions?
- A. Onset of labor in a pregnant woman
- B. Stroke
- C. Heart attack
- D. Migraine
Correct answer: B
Rationale: The correct answer is B: Stroke. The acronym FAST is used to help recognize the signs of a stroke. The letters stand for Face, Arms, Speech, and Time. This mnemonic helps in identifying facial drooping, arm weakness, speech difficulties, and the importance of time in seeking emergency care. Choices A, C, and D are incorrect because the FAST acronym specifically pertains to stroke recognition, not the onset of labor, heart attacks, or migraines.
5. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?
- A. Help the client to get settled and conduct the interview the next morning when the client is rested
- B. Conduct the interview immediately, directing the majority of the questions to the client
- C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns
- D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication
Correct answer: C
Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.
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