you are caring for a hispanic patient who is scheduled for surgery in the morning a member of the surgery staff is in a hurry when she visits the pati

NCLEX-RN

NCLEX RN Practice Questions With Rationale

1. You are caring for a Hispanic patient who is scheduled for surgery in the morning. A member of the surgery staff is in a hurry when she visits the patient to obtain surgical consent. You know that the patient speaks limited English and can see that he does not really understand what's being said. What is the most appropriate next action?

A. Call a family member to interpret
B. Consult the hospital translator to assist
C. Allow the consent to be signed
D. Ask the staff member to come back later

Correct answer: B

Rationale: Consulting the hospital translator is the most reliable means of ensuring accuracy in the information that the patient is receiving. Family members can be helpful, but they may have difficulty understanding the medical procedures well enough to explain them accurately and may misinterpret the message. Relying on family members could lead to misunderstandings or miscommunication. Allowing the consent to be signed without ensuring the patient's full understanding could pose risks to the patient's well-being. Asking the staff member to come back later delays the essential communication process needed before surgery. Therefore, consulting the hospital translator is the best course of action to ensure clear and accurate communication, especially in critical healthcare decisions like surgical consent.

2. Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for:

A. Rest, Ice, Compression, Elevation
B. Radiology, Ice, Compression, Elevation
C. Rest, Ice, Cast, Elevation
D. Radiology, Ice, Cast, Elevation

Correct answer: A

Rationale: The correct answer is Rest, Ice, Compression, Elevation. This acronym, RICE, is commonly used for the treatment of injuries like an ankle sprain. Rest allows the injured area to heal, Ice helps reduce swelling and pain (20 minutes on each hour while awake), Compression is usually achieved with an elastic bandage to minimize swelling, and Elevation of the foot above the level of the heart assists in reducing swelling and promoting healing. Choices B, C, and D are incorrect because they include irrelevant terms like Radiology and Cast, which are not part of the standard treatment protocol for an ankle sprain.

3. You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key item should NOT be included in the teaching plan?

A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
B. Avoid drugs such as Tagamet, nitroglycerin, and Nifedipine.
C. Continue taking estrogen as prescribed by your physician.
D. A potential side effect of medications is rebound headache.

Correct answer: C

Rationale: The correct answer is C: Continue taking estrogen as prescribed by your physician. Medications such as estrogen supplements may actually trigger a migraine headache attack. Fluctuations in estrogen, such as before or during menstrual periods, pregnancy, and menopause, seem to trigger headaches in many women. Choices A and B are important to include in the teaching plan for a patient with migraines as avoiding foods containing tyramine and certain drugs can help prevent migraine triggers. Choice D is also relevant as it is essential for the patient to be aware of potential side effects of medications, including rebound headaches.

4. What preparation is necessary for a colposcopy procedure?

A. NPO for 8-12 hours before the procedure.
B. D/C all hypertension medications for two days prior to the procedure.
C. Take three Dulcolax tablets and two containers of Miralax the day before to clear out the lower GI system.
D. None of the above prep is necessary for this type of procedure.

Correct answer: D

Rationale: A colposcopy procedure is performed to examine the vagina and cervix. The only preparation required is washing the external genitals with soap and water on the morning of the procedure. Choices A, B, and C suggest unnecessary preparations that are not relevant to a colposcopy. NPO for 8-12 hours, discontinuing hypertension medications, and using laxatives are not part of the standard preparation for a colposcopy.

5. At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?

A. A 91-year-old man who needs help eating breakfast
B. An 86-year-old man who has been incontinent in his bed
C. An 82-year-old woman who needs IV antibiotics
D. A 75-year-old man who is recovering from an injury and needs an ice pack

Correct answer: C

Rationale: When prioritizing care in a long-term care facility, the nurse must consider tasks that require their immediate attention and cannot be delegated. Administering IV antibiotics is a critical nursing task that only the nurse can perform, ensuring the timely and correct delivery of medication to the patient. While assisting with breakfast, managing incontinence, and providing an ice pack are important, these tasks can be delegated to other healthcare team members, allowing the nurse to address the client needing IV antibiotics first to ensure effective treatment and patient safety.