you are taking care of 7 patients today one of your residents wants water another needs help walking to the bathroom another just stated that they hav
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Nursing Elites

NCLEX-RN

NCLEX RN Exam Prep

1. You are taking care of 7 patients today. One of your residents wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care task is the lowest in terms of priority?

Correct answer: D

Rationale: The lowest priority patient care task in this scenario is addressing the emotional need of the patient who is crying because his daughter did not visit him today. While emotional support is important, the other needs - providing water, assisting to the bathroom, and addressing chest pain - are physical needs that must take priority as they directly impact the patient's well-being and health. It is crucial to acknowledge and address emotional needs but in this situation, the physical needs of the patients should be addressed first.

2. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?

Correct answer: D

Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.

3. When cleansing the genital area during perineal care, the nurse should _____________.

Correct answer: B

Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.

4. Which of the following actions can help prevent a fire in the area where a healthcare professional works?

Correct answer: C

Rationale: The correct action to help prevent a fire in a healthcare setting is to notify visitors or post signs indicating that oxygen is in use in certain areas. Oxygen is a combustible material, and awareness of its presence is crucial to prevent fire hazards. By informing all individuals in the facility about the use of oxygen through clear signs or notifications, the risk of improper use and potential fire accidents can be minimized. Choice A is incorrect because using an adaptor when plugging in client equipment is not directly related to fire prevention. Choice B is also incorrect as marking faulty equipment and using it until inspection does not directly address fire prevention. Choice D is not a recommended action for fire prevention; storing extra equipment with supplies does not address the specific fire risk associated with oxygen use.

5. What is the MOST ACCURATE statement regarding the ESR test?

Correct answer: C

Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.

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