NCLEX-RN
NCLEX RN Predictor Exam
1. Which of the following lists the recommended sequence for removing soiled personal protective equipment when preparing to leave a patient's room?
- A. Gown, goggles, mask, gloves, and exit the room.
- B. Gloves, wash hands, remove gown, mask, and goggles.
- C. Gloves, goggles, gown, mask, and wash hands.
- D. Gloves, goggles, gown, mask, and wash hands.
Correct answer: D
Rationale: The correct sequence for removing soiled personal protective equipment is crucial to prevent contamination. Gloves should always be removed first as they are most likely to be contaminated. Following the removal of gloves, goggles, gown, mask, and finally washing hands is recommended. Choice A is incorrect as gloves should be removed first. Choice B is incorrect as the sequence is not in the recommended order. Choice D is incorrect as gloves should be removed before goggles.
2. Which of these specific measurements is the best index of a child's general health?
- A. Body mass index
- B. Height and weight
- C. Head circumference
- D. Chest circumference
Correct answer: B
Rationale: Height and weight are the most accurate measurements to assess a child's general health. These measurements reflect the physical growth and development of the child, indicating overall health status. Choices C and D, head circumference and chest circumference, are important measurements for specific assessments but do not provide as comprehensive an overview of general health as height and weight. Body mass index (BMI) is a calculation based on height and weight, making height and weight more direct and primary indicators of a child's health compared to BMI.
3. An adult patient is at the clinic for a physical examination. The patient states that they are feeling 'very anxious' about the physical examination. What steps can the nurse take to make the patient more comfortable?
- A. Appear unhurried and confident when examining the patient.
- B. Leave the room when the patient undresses unless they need assistance.
- C. Ask the patient to change into an examining gown and to leave their undergarments on.
- D. Measure vital signs at the beginning of the examination to gradually accustom the patient.
Correct answer: A
Rationale: To help alleviate the patient's anxiety, the nurse should appear unhurried and confident during the examination. This can make the patient feel more at ease and reassured. It is important for the nurse to respect the patient's privacy by leaving the room while the patient changes unless assistance is needed. The patient should be instructed to change into an examining gown while leaving their undergarments on, providing a sense of comfort and familiarity. Additionally, measuring vital signs at the beginning of the examination can help gradually acclimate the patient to the process, making it less overwhelming. Therefore, the correct answer is to appear unhurried and confident when examining the patient. Choices B, C, and D are incorrect because they do not directly address the patient's anxiety or provide comfort in the same way as the correct answer.
4. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?
- A. A person of small stature is at increased risk for injury from entrapment.
- B. A history of a previous fall from a bed with raised side rails is significant.
- C. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails.
- D. Creative use of alternative measures indicates respect for the patient's dignity.
Correct answer: A
Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.
5. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from?
- A. Cataracts
- B. Glaucoma
- C. Astigmatism
- D. Presbyopia
Correct answer: D
Rationale: Presbyopia is a condition that occurs when the lens of the eye loses accommodation and is unable to focus light on objects nearby. As a result, clients are unable to see or read items up close but may have success when holding the same item at arm's length. Many clients with presbyopia must wear bifocals, but long-distance vision remains unaffected. Cataracts involve clouding of the eye's lens, leading to blurry vision. Glaucoma is associated with increased intraocular pressure that damages the optic nerve, causing vision loss. Astigmatism is a refractive error where the cornea or lens has an irregular shape, leading to distorted or blurred vision.
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