NCLEX-RN
NCLEX RN Predictor Exam
1. Efforts by healthcare facilities to reduce the incidence of hospital-acquired infections (HAIs) include an awareness of which of the following?
- A. The CDC requires all states to report HAI rates from each hospital.
- B. Ensure that the restraints are tied to the side rails.
- C. The gastrointestinal tract is a common site for HAIs.
- D. Joint Commission considers death or serious injury from HAIs a sentinel event.
Correct answer: D
Rationale: Efforts to reduce hospital-acquired infections (HAIs) involve being aware that the Joint Commission considers death or serious injury resulting from HAIs a sentinel event, which must be reported. While more than 20 states require reporting of HAI rates to the CDC, it is not a nationwide CDC requirement. The gastrointestinal tract is not a specific common site for HAIs; rather, bacteria are the primary cause. Ensuring restraints are properly secured is important for patient safety but not directly related to reducing HAIs.
2. Which of the following lists the recommended sequence for removing soiled personal protective equipment when preparing to leave a patient's room?
- A. Gown, goggles, mask, gloves, and exit the room.
- B. Gloves, wash hands, remove gown, mask, and goggles.
- C. Gloves, goggles, gown, mask, and wash hands.
- D. Gloves, goggles, gown, mask, and wash hands.
Correct answer: D
Rationale: The correct sequence for removing soiled personal protective equipment is crucial to prevent contamination. Gloves should always be removed first as they are most likely to be contaminated. Following the removal of gloves, goggles, gown, mask, and finally washing hands is recommended. Choice A is incorrect as gloves should be removed first. Choice B is incorrect as the sequence is not in the recommended order. Choice D is incorrect as gloves should be removed before goggles.
3. The nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range?
- A. Once a shift
- B. Once an hour
- C. Every 2 hours
- D. Every 4 hours
Correct answer: C
Rationale: Restraints should be removed every 2 hours to prevent complications. Moving the joints through their full range of motion helps prevent muscle shortening and contractures. Massaging the area promotes circulation and reduces the risk of pressure injuries. Removing restraints less frequently could lead to complications like decreased circulation and skin breakdown. Options A, B, and D are incorrect because they do not align with the standard practice of removing restraints every 2 hours to ensure patient safety and well-being.
4. A patient's urine specimen tested positive for bilirubin. Which of the following is most true?
- A. The patient should be evaluated for kidney disease
- B. The specimen was probably left at room temperature for more than two hours
- C. The specimen is positive for bacteria
- D. The specimen should be stored in an area protected from light
Correct answer: D
Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing. Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease. Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels. Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.
5. For a healthcare worker under normal conditions with unsoiled hands, effective hand hygiene between patients requires which of the following?
- A. At least a 15-second scrub with plain soap and water
- B. At least a 23-minute scrub with an antimicrobial soap
- C. Use of an alcohol-based antiseptic hand-rub
- D. Wearing a mask when scrubbing
Correct answer: C
Rationale: Effective hand hygiene between patients for a healthcare worker with unsoiled hands involves using an alcohol-based antiseptic hand rub. This method is sufficient for cleaning hands that are not visibly soiled. The use of an antimicrobial soap or a prolonged scrubbing time is unnecessary and not recommended in this scenario. Wearing a mask is not required for routine hand hygiene and does not contribute to effective hand cleaning.
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