NCLEX-RN
NCLEX RN Exam Prep
1. Which of the following is a disadvantage of using a dry heat application?
- A. Dry heat is more likely to cause burns than moist heat
- B. Dry heat does not penetrate deeply into the tissues
- C. Dry heat causes the skin to dry out more quickly
- D. Dry heat can quickly cause skin breakdown
Correct answer: C
Rationale: The correct answer is that dry heat causes the skin to dry out more quickly. When comparing dry and moist heat applications, dry heat is less likely to cause burns and skin breakdown. However, one of the disadvantages of dry heat is that it does not penetrate deeply into the tissues and may lead to faster drying out of the skin. This can have negative effects on skin integrity and overall comfort during therapy. Choice A is incorrect because dry heat is less likely to cause burns than moist heat. Choice B is incorrect as dry heat may not penetrate deeply into tissues. Choice D is incorrect as dry heat is less likely to cause skin breakdown compared to moist heat.
2. A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: Less than body requirements
- B. Chronic low self-esteem
- C. Risk for suicide
- D. Hopelessness
Correct answer: B
Rationale: The priority nursing diagnosis in this scenario is 'Risk for suicide.' When a patient presents with major depression, significant weight loss, suicidal ideation, and lack of symptom improvement despite medication, the immediate concern is to address the risk of suicide. 'Risk for suicide' takes precedence as it involves a direct threat to the patient's life. 'Imbalanced nutrition: Less than body requirements' may be a concern but does not take priority over the risk of suicide. 'Chronic low self-esteem' and 'Hopelessness' are relevant issues in depression but are not as urgent as addressing the immediate risk of suicidal behavior.
3. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when assessing a patient?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct answer: A
Rationale: The correct answer is Palpation. Palpation involves using the sense of touch to assess texture, temperature, moisture, and swelling in a patient. This technique allows the nurse to feel for abnormalities and changes in the patient's tissues. Inspection primarily relies on visual assessment, while percussion involves tapping on the body to produce sounds and assess underlying structures. Auscultation, on the other hand, involves listening to sounds within the body using a stethoscope. Therefore, in the context of assessing texture, temperature, moisture, and swelling, palpation is the most appropriate technique.
4. What is the most useful patient position for proctologic exams?
- A. Trendelenburg
- B. Semi-Fowler's
- C. Full Fowler's
- D. Jack Knife
Correct answer: D
Rationale: The Jack Knife position is the most useful for proctologic exams as it allows the patient to lie face down while keeping the buttocks elevated, providing optimal access for the examination. The Trendelenburg position, characterized by the body being laid flat with the feet higher than the head, is not suitable for proctologic exams. Semi-Fowler's and Full Fowler's positions are typically utilized for respiratory or cardiovascular conditions and are not ideal for proctologic examinations due to their lack of optimal access to the perianal area.
5. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
- A. Angina at rest
- B. Thrombus formation
- C. Dizziness
- D. Falling blood pressure
Correct answer: B
Rationale: Thrombus formation is a critical complication of cardiac catheterization that the nurse should monitor for in the initial 24 hours after the procedure. A thrombus can form in the blood vessels, obstructing blood flow and potentially leading to serious consequences such as embolism or organ ischemia. While angina at rest, dizziness, and falling blood pressure are potential complications following cardiac catheterization, they are not typically associated with the immediate post-procedural period. Monitoring for thrombus formation is essential to ensure early detection and intervention, which can prevent serious complications.
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