NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. When escorting a patient to the operating room on a stretcher, what should you do to prevent the patient from falling?
- A. Ensure the safety belt or strap is secured on the patient while escorting them to the operating room
- B. Use a safety belt or strap on the patient throughout their escort to the operating room
- C. Lower the bed position when moving the patient from the bed to the stretcher
- D. All of the above options are correct
Correct answer: B
Rationale: When escorting a patient to the operating room on a stretcher, it is crucial to secure a safety belt or strap on the patient to prevent falls during the transfer. This safety measure is not considered a restraint but a necessary precaution. Lowering the bed position is not necessary; in fact, the bed should be in a high position to align with the stretcher. Locking the wheels of the stretcher is essential to prevent accidents during patient transfer. Therefore, the correct action to prevent falls while moving a patient to the operating room is to use a safety belt or strap on the patient throughout the escort.
2. A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?
- A. A statement explaining the condition the client was found in, quoting the client's words about the situation
- B. An explanation of how the fall happened and when the physician was notified
- C. An account of the conditions of the room that contributed to the client's fall
- D. A summary of the client's medical history and current medications
Correct answer: A
Rationale: When a fall or injury occurs while under nursing care, it is crucial to document the known aspects of the situation and the response to the injury. In this scenario, the nurse should document the client's condition as found and quote the client's own words about the situation. This helps provide a clear account of the event without implying blame. Options B, C, and D are incorrect because detailing how the fall happened, listing room conditions, or summarizing medical history are not directly relevant to documenting the immediate situation and the client's own words following the fall.
3. The chain of infection includes the ________________.
- A. germ, agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host
- B. active natural, active artificial, passive natural, and passive artificial
- C. opportunism, weakness, immunity, and colonization
- D. intrinsic, extrinsic, internal, and external transmission
Correct answer: A
Rationale: The chain, or cycle, of infection includes the germ (microorganism), agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host. This sequence describes how infections are passed from one person to another. Choice B is incorrect because it refers to types of immunity, not components of the chain of infection. Choice C is also incorrect as it lists terms unrelated to the chain of infection. Choice D is incorrect as it describes transmission types, not components of the chain of infection. Understanding the chain of infection is crucial in preventing the spread of infections by breaking one or more links in the chain, such as interrupting the mode of transmission through proper hand hygiene.
4. Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?
- A. Standard four-drug therapy for TB
- B. Need for annual repeat TB skin testing
- C. Use and side effects of isoniazid (INH)
- D. Bacille Calmette-Gurin (BCG) vaccine
Correct answer: C
Rationale: The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.
5. An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease?
- A. Treat workers with pulmonary fibrosis.
- B. Teach about symptoms of lung disease.
- C. Require the use of protective equipment.
- D. Monitor workers for coughing and wheezing.
Correct answer: C
Rationale: Prevention of lung disease requires the use of appropriate protective equipment such as masks to reduce exposure to inhaled dust, which is a significant risk factor for lung disease. Teaching about symptoms of lung disease, treating workers with pulmonary fibrosis, and monitoring for coughing and wheezing are important actions for early recognition and treatment of lung disease. However, the most effective strategy to prevent lung damage in this scenario is to require the use of protective equipment to minimize exposure to harmful substances.
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