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. A client is suspected of having carbon monoxide poisoning. Which of the following symptoms are associated with this condition?

A. Red rash across the trunk and extremities
B. Nausea, vomiting, seizures
C. Flushing of the face and neck
D. Abdominal pain radiating to the back

Correct answer: B

Rationale: The correct answer is 'Nausea, vomiting, seizures.' Carbon monoxide poisoning can present with symptoms such as headache, dizziness, weakness, nausea, vomiting, and confusion. Severe cases can progress to seizures, coma, and even death. It is crucial for healthcare providers to recognize these symptoms promptly to initiate appropriate treatment. Choices A, C, and D are incorrect because a red rash, flushing of the face and neck, and abdominal pain radiating to the back are not typically associated with carbon monoxide poisoning. It is essential to be aware of the common manifestations of carbon monoxide poisoning to ensure timely intervention and prevent adverse outcomes.

3. A healthcare professional is employed at a district health department and must spend several hours each day sitting at a desk. Which principle of ergonomics will most likely help them to reduce the risk of injury or pain in this situation?

A. Adjust the chair height to keep the legs bent at the hips at a 90-degree angle
B. Maintain the position of the computer monitor just below eye level
C. Stand up and take a walk or stretch every 4 hours
D. Rest wrists on the edge of the desk while typing

Correct answer: A

Rationale: When sitting for prolonged periods, it is important to adjust the height of the chair so that the legs are bent at the hips at a 90-degree angle. This position helps to reduce pressure on the back, legs, and feet, promoting better posture and reducing muscle fatigue. Standing up and moving around at least once every hour is crucial to support circulation and prevent stiffness. Maintaining the position of the computer monitor just below eye level helps reduce strain on the neck and eyes. Resting wrists on the edge of the desk while typing can lead to wrist strain and discomfort, so it is not an ergonomic recommendation for prolonged desk work.

4. For a patient who is blood type AB, which blood product can they receive?

A. Plasma from a type B donor
B. Whole blood from a type A donor
C. Packed RBCs from a type O donor
D. All of the above

Correct answer: C

Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens. Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma. Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens. Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type. Therefore, choices A and B are incorrect, and the correct choice is C.

5. You are taking care of a patient who has active TB. The patient has been put on airborne precautions and is in a special room. You must wear a HEPA mask when you enter the room. Now, the patient has to leave the room and go to the radiology department. How can you transport this patient to the radiology department without spreading TB throughout the hospital?

A. Have everyone along the route to the radiology department wear a HEPA mask.
B. Have patients along the route to the radiology department wear a HEPA mask.
C. Have staff along the route to the radiology department wear a HEPA mask.
D. Place a HEPA mask on the patient.

Correct answer: D

Rationale: To prevent the spread of TB throughout the hospital, it is essential to place a HEPA mask on the patient before transporting them to the radiology department. Expecting everyone along the route to wear a HEPA mask is not practical due to the high cost and the need for special fittings. Having patients or staff wear HEPA masks along the route is also not feasible and may not effectively contain the spread of TB.