while assisting a client from bed to chair the nurse observes that the client looks pale and is beginning to perspire heavily the nurse would then do

NCLEX-RN

NCLEX RN Predictor Exam

1. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?

A. Help client into the chair more quickly
B. Document client's vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set of vital signs

Correct answer: D

Rationale: In this scenario, the nurse has observed concerning signs in the client during the transfer process. The appropriate action for reassessment would be to observe the client's skin color and take another set of vital signs. This will provide essential data to evaluate the client's condition more accurately. Options A, B, and C are interventions that do not address the need for reassessment. Moving the client more quickly, documenting previous vital signs, or returning the client to bed do not directly address the need to reassess the client's current condition.

2. The nurse is unable to palpate the right radial pulse on a patient. What would the nurse do next?

A. Auscultate over the area with a fetoscope.
B. Use a goniometer to measure the pulsations.
C. Use a Doppler device to check for pulsations over the area.
D. Check for the presence of pulsations with a stethoscope.

Correct answer: C

Rationale: When a nurse is unable to palpate a radial pulse, the next step is to use a Doppler device to check for pulsations over the area. Doppler devices are specifically designed to augment pulse or blood pressure measurements. Auscultating with a fetoscope is used to listen to fetal heart tones and is not relevant in this scenario. Goniometers are used to measure joint range of motion and are not used to assess pulses. Stethoscopes are primarily used to auscultate breath, bowel, and heart sounds, not to check for pulsations in peripheral pulses. Therefore, the correct course of action when unable to palpate a pulse is to utilize a Doppler device to assess for pulsations in the radial pulse area.

3. What procedure examines a portion of the large intestine with an endoscope?

A. Colposcopy
B. Sigmoidoscopy
C. Upper GI
D. Cardiac catheterization

Correct answer: B

Rationale: Sigmoidoscopy is the correct answer because it specifically examines the sigmoid colon located in the descending colon using an endoscope inserted through the rectum. This procedure captures video and images of the large intestine's lining, helping in the diagnosis of conditions like inflammatory bowel disease or colorectal cancer. Colposcopy, on the other hand, is a procedure for examining the cervix and vagina, not the large intestine. Upper GI involves capturing images of the esophagus and stomach, focusing on the upper gastrointestinal tract, not the large intestine. Cardiac catheterization is a procedure that involves threading a thin instrument through the femoral artery to the heart, used for cardiac interventions and not related to examining the large intestine.

4. In a 68-year-old man, a gradual loss of hearing is known as _____________.

A. presbycusis
B. xerostomia
C. myopia
D. presbyopia

Correct answer: A

Rationale: The correct answer is 'presbycusis.' Presbycusis is the age-related gradual loss of hearing ability, commonly seen in the elderly population. Xerostomia refers to dry mouth, myopia is nearsightedness, and presbyopia is the age-related loss of the eye's ability to focus on close objects. Given Mr. Roberts' age and symptom of gradual hearing loss, presbycusis is the most likely diagnosis. Xerostomia, myopia, and presbyopia do not match the sensory change described in the question, making them incorrect choices.

5. Which of the following diseases would require the nurse to wear an N95 respirator as part of personal protective equipment?

A. Human immunodeficiency virus
B. Clostridium difficile enterocolitis
C. Vancomycin-resistant enterococcus
D. Measles

Correct answer: D

Rationale: Infections that require airborne precautions necessitate the use of an N95 respirator, a type of mask that filters particles that are 5 micrograms or smaller. Illnesses that require airborne precautions include Measles, Varicella, Severe Acute Respiratory Syndrome (SARS), and tuberculosis. Measles is a highly contagious airborne disease caused by a virus. It can spread through respiratory droplets when an infected person coughs or sneezes. Wearing an N95 respirator helps prevent the nurse from inhaling these infectious particles. Human immunodeficiency virus, Clostridium difficile enterocolitis, and Vancomycin-resistant enterococcus do not require the use of an N95 respirator as they are not transmitted through the air but have other modes of transmission.