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. An older adult patient brought to the emergency department by a family member is wandering outside, saying, "I can't find my way home."? The patient is confused and unable to answer questions. What is the nurse's best action?
- A. Document the patient's mental status and obtain other assessment data from the family member.
- B. Record the patient's answers to questions on the nursing assessment form.
- C. Ask an advanced practice nurse to perform the assessment interview.
- D. Call for a mental health advocate to maintain the patient's rights.
Correct answer: A
Rationale: In this scenario, the patient is confused and unable to answer questions. When the patient is unable to provide information, it is important to use secondary sources such as family members. The nurse's best action is to document the patient's mental status and obtain additional assessment data from the family member. This approach will help gather relevant information about the patient's condition. Asking an advanced practice nurse to perform the assessment interview is not necessary as it is within the staff nurse's scope of practice. Calling for a mental health advocate is also unnecessary at this point as the priority is to assess the patient's condition and gather information from the family member.
3. What is the primary purpose of emergency planning?
- A. Comply with the laws of the state.
- B. Comply with the laws of the U.S.
- C. Comply with both state and U.S. laws
- D. Maintain safety
Correct answer: D
Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.
4. Where is the pulse point located on the top of the foot?
- A. the dorsalis pedis
- B. This is the pulse point checked in patients with peripheral vascular problems.
- C. This pulse point may be absent in some patients due to a congenital anomaly.
- D. All of the above.
Correct answer: D
Rationale: The pulse point located on the top of the foot is known as the dorsalis pedis pulse point. It is situated on the arch of the foot, slightly lateral to the midline. This pulse point is commonly examined in patients with peripheral vascular problems to assess blood flow adequacy. Additionally, some individuals may not have this pulse point due to a congenital anomaly. Therefore, all the given statements are correct in relation to the dorsalis pedis pulse point, making 'All of the above' the correct answer. Choices A, B, and C are all individually valid characteristics of the dorsalis pedis pulse point, hence selecting 'All of the above' as the correct answer is appropriate.
5. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?
- A. Blood pressure guidelines for children are based on age.
- B. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
- C. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence.
- D. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
Correct answer: D
Rationale: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. Blood pressure guidelines for children are based on more than just age, but also sex and height. Phase I Korotkoff, not Phase II, is the best indicator of systolic blood pressure. The true statement regarding the measurement of blood pressure in children is that the disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.
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