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
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Nursing Elites

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?

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

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.

3. When caring for children with a different cultural perspective, what challenge may the nurse recognize?

Correct answer: A

Rationale: When caring for children with different cultural perspectives, nurses should acknowledge that children have spiritual needs that are influenced by their stages of development. This understanding is crucial as children, like adults, have varying spiritual needs based on their age and the religious environment within their family. Recognizing and addressing these spiritual needs is essential for providing holistic care. Choices B, C, and D are incorrect as they do not accurately reflect the influence of children's developmental stages on their spiritual needs and the importance of considering these needs in their care.

4. A client is being transferred from a bed to a wheelchair. Which action is essential to maintain client safety in this situation?

Correct answer: D

Rationale: When transferring a client from a bed to a wheelchair, it is crucial to prioritize client safety. Locking both wheels on the wheelchair before moving the client is essential as it adds stability and prevents the wheelchair from moving unexpectedly during the transfer process. Placing the wheelchair at the foot of the bed allows for easier transfer, but ensuring the wheels are locked is more critical for safety. Maintaining a 12-inch space between the wheelchair and the bed is not as essential as ensuring wheel locks are engaged. While placing the footplates in the lowest position can enhance client comfort, it is not a safety measure that is as critical as securing the wheelchair by locking its wheels before the transfer.

5. During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?

Correct answer: B

Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.

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