NCLEX-RN
NCLEX RN Exam Prep
1. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?
- A. Get the nurse who is caring for the patient.
- B. Tell the nurse that the patient has had another seizure.
- C. Observe the patient for any injuries and call out for help.
- D. Nothing. This patient is not one of your assignments.
Correct answer: C
Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.
2. Patients have a right to ______________.
- A. only enough information so they can comply with care
- B. ALL of their health-related information
- C. small amounts of information so they do not get nervous
- D. moderate amounts of information unless they are old
Correct answer: B
Rationale: Patients have a legal right to access all of their health-related information. This includes details about their health condition, treatment options, test results, and any other relevant data. Providing patients with all their health-related information empowers them to make informed decisions about their care, promotes transparency in the healthcare process, and respects their autonomy. Choices A, C, and D are incorrect because they restrict the information patients should receive based on assumptions or limitations, which goes against the principle of patient autonomy and their right to access their complete health-related information.
3. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse would take when performing a physical examination?
- A. Washing one's hands after removing gloves is necessary, even if the gloves are still intact
- B. Hands are washed before and after every physical patient encounter
- C. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another
- D. Gloves are worn throughout the entire examination to demonstrate concern regarding the spread of infectious diseases
Correct answer: B
Rationale: The most appropriate action for the nurse to take when performing a physical examination is to wash their hands before and after every physical patient encounter. This practice helps prevent the spread of infection. Hands should also be washed after contact with blood, body fluids, secretions, and excretions, and after contact with any equipment contaminated with body fluids. It is crucial to wash hands after removing gloves, even if the gloves appear intact. Choice A is incorrect because washing hands after removing gloves is necessary to ensure thorough hygiene. Choice C is incorrect because hands should be washed before and after every patient encounter, not just before examining each body system. Choice D is incorrect because gloves should be worn when there is potential contact with body fluids, but they do not need to be worn throughout the entire examination.
4. 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.
5. A client is diagnosed with ariboflavinosis. Which of the following foods should the nurse serve this client?
- A. Citrus fruits
- B. Milk
- C. Fish
- D. Potatoes
Correct answer: B
Rationale: Ariboflavinosis is a vitamin B-2 deficiency. Symptoms may include cracks around the mouth, inflammation of the tongue, or light sensitivity. Foods rich in vitamin B-2, like milk, liver, green vegetables, or whole grains, are recommended. Citrus fruits (choice A) are good sources of vitamin C, not B-2. Fish (choice C) is a source of protein and omega-3 fatty acids but not a significant source of vitamin B-2. Potatoes (choice D) are a source of carbohydrates but do not provide high levels of vitamin B-2.
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