you are taking care of mary eden she is an elderly and frail 91 year old resident she gets confused during evening hours and at times she thinks that
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Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. You are taking care of Mary Eden, an elderly and frail 91-year-old resident. She gets confused during evening hours and at times she thinks that she hears her daughter calling her from the other side of the nursing home. Which physical problem places Mary Eden at risk for falls?

Correct answer: D

Rationale: Mary Eden's frail and weak muscles due to her age and physical condition place her at risk for falls. While her confusion can contribute to falls, it is considered an emotional or cognitive issue rather than a physical problem. Her daughter and the evening hours are not physical problems that directly increase her risk of falling.

2. A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?

Correct answer: A

Rationale: After pregnancy, women with MS are at higher risk for exacerbation of symptoms due to the postpartum period. There is no increased risk for congenital defects in infants born to mothers with MS. Symptoms of MS may actually improve during pregnancy, likely due to hormonal changes. MS does not significantly impact the onset of labor. Therefore, the correct response is that MS symptoms may worsen after pregnancy, making option A the accurate answer. Options B, C, and D are incorrect as they do not accurately reflect the risks associated with pregnancy in individuals with MS.

3. A healthcare professional is preparing to draw a blood specimen from an adult client's central line. All of the following actions for this procedure are correct EXCEPT:

Correct answer: B

Rationale: When drawing a blood specimen from a central line, the healthcare professional should disconnect any infusions that are currently running and that could contaminate the specimen. It is important to use a minimum size of a 10 cc syringe when using a central line to avoid placing too much pressure on the catheter. Cleaning the cap with alcohol and attaching a 5 cc syringe is not appropriate as a larger syringe size should be used for this procedure. Drawing 5 cc of a blood sample to discard and flushing with saline after the sample are correct steps in the process of drawing a blood specimen from a central line.

4. Which of the following may be a cultural barrier that impacts a healthcare provider's ability to provide care or education to the client?

Correct answer: C

Rationale: Cultural barriers can impede communication, hindering a healthcare provider's ability to provide education or instructions about a client's care. In the context of cultural sensitivity, using pantomime to explain a procedure to a deaf client can be ineffective and inappropriate. This approach implies a lack of recognition of the importance of proper communication methods, such as sign language interpreters, which are crucial for effective communication with individuals who are deaf. Miscommunication is likely to occur if the client does not understand the gestures and actions of the healthcare provider. This scenario highlights the significance of understanding and respecting different cultural practices and communication needs to deliver optimal care and education. Choice A is incorrect because offering educational materials at an appropriate reading level demonstrates consideration for the client's literacy level, which can enhance understanding and compliance with medical instructions. Choice B is incorrect as incorporating a client's cultural practices, such as steaming, alongside prescribed treatments can be a part of culturally competent care. Choice D is incorrect as respecting a client's request for a healing ritual aligns with providing patient-centered care that acknowledges and integrates cultural beliefs and preferences.

5. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, "My blood pressure is usually much lower."? The nurse should tell the client to:

Correct answer: A

Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke. Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (Choice B) or a week (Choice D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (Choice C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.

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