NCLEX-RN
NCLEX RN Exam Preview Answers
1. Which of these statements is true regarding the use of Standard Precautions in the healthcare setting?
- A. Standard Precautions apply to all body fluids, except sweat.
- B. Alcohol-based hand rub should be used if hands are not visibly dirty.
- C. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
- D. Standard Precautions are to be used only when non-intact skin, excretions containing visible blood, or expected contact with mucous membranes are present.
Correct answer: C
Rationale: Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources. They are intended for use with all patients, regardless of their risk or presumed infection status. Standard Precautions apply to all body fluids, secretions, and excretions except sweat - whether or not they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. Choice A is incorrect because Standard Precautions apply to all body fluids, secretions, and excretions except sweat. Choice B is incorrect because alcohol-based hand rub should be used when hands are not visibly dirty. Choice D is incorrect because Standard Precautions are not limited to situations involving non-intact skin, excretions with visible blood, or expected mucous membrane contact.
2. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse would take when performing a physical examination?
- A. Washing one's hands after removing gloves is necessary, even if the gloves are still intact
- B. Hands are washed before and after every physical patient encounter
- C. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another
- D. Gloves are worn throughout the entire examination to demonstrate concern regarding the spread of infectious diseases
Correct answer: B
Rationale: The most appropriate action for the nurse to take when performing a physical examination is to wash their hands before and after every physical patient encounter. This practice helps prevent the spread of infection. Hands should also be washed after contact with blood, body fluids, secretions, and excretions, and after contact with any equipment contaminated with body fluids. It is crucial to wash hands after removing gloves, even if the gloves appear intact. Choice A is incorrect because washing hands after removing gloves is necessary to ensure thorough hygiene. Choice C is incorrect because hands should be washed before and after every patient encounter, not just before examining each body system. Choice D is incorrect because gloves should be worn when there is potential contact with body fluids, but they do not need to be worn throughout the entire examination.
3. The abbreviation pc is defined as ________________.
- A. before the meal
- B. with the meal
- C. after the meal
- D. post corpi
Correct answer: C
Rationale: The correct answer is C: 'after the meal.' In medical terminology, 'pc' is an abbreviation for 'post cibum,' which means 'after eating' or 'after the meal.' This term is used to indicate when a medication should be taken concerning meals. Choices A, B, and D are incorrect. 'Before the meal' (A) is typically abbreviated as 'ac,' 'with the meal' (B) is abbreviated as 'pc,' and 'post corpi' (D) is not a valid medical abbreviation or term.
4. 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.
5. During an examination, a nurse notices a draining ulceration on a patient's lower leg. What is the most appropriate action in this situation?
- A. Wash hands and then contact the physician.
- B. Continue to examine the ulceration and then wash hands.
- C. Wash hands, put on gloves, and continue with the examination of the ulceration.
- D. Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last.
Correct answer: C
Rationale: In this scenario, the most appropriate action is to wash hands, put on gloves, and then continue examining the ulceration. Wearing gloves is crucial when there is a possibility of contact with body fluids, as in the case of a draining ulceration. Contacting the physician is not necessary at this point; the immediate focus should be on proper infection control by washing hands and wearing gloves. Changing the order of the examination is not recommended as it is important to follow a systematic approach to avoid missing any crucial assessments.
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