NCLEX-RN
NCLEX RN Predictor Exam
1. Digestion, elimination, and ___________ are the three functions of the digestive system.
- A. constriction
- B. relaxation
- C. absorption
- D. peristalsis
Correct answer: C
Rationale: The correct answer is 'absorption.' The three main functions of the digestive system are digestion, absorption, and elimination. Absorption refers to the process of absorbing nutrients and other substances from the digested food into the bloodstream. Choices A, B, and D are incorrect: Constriction is not a primary function of the digestive system, relaxation is not a distinct function in this context, and peristalsis is a muscular movement that aids in digestion but is not one of the three main functions of the digestive system.
2. 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.
3. A patient's Foley catheter has been discontinued. You will dispose of this patient equipment by doing which of the following?
- A. Wearing gloves and then placing this equipment in the regular trash can after it is placed in a paper bag.
- B. Simply placing this equipment in the regular trash can after it is placed in a paper bag.
- C. Wearing gloves and then placing this equipment into a special 'hazardous waste' container.
- D. Simply placing this equipment in the 'hazardous waste' container after it is placed in a paper bag.
Correct answer: C
Rationale: When disposing of used patient equipment, such as a Foley catheter, that has come in contact with bodily fluids, it is considered hazardous waste. The correct procedure involves wearing gloves and placing the Foley bag and tubing into a special 'hazardous waste' container. This container is marked as 'Hazardous' and is typically red to indicate the potential danger of its contents. Placing the equipment in a regular trash can, even if placed in a paper bag, is not appropriate as it does not meet the standards for disposing of hazardous waste. Therefore, options A and B are incorrect. Similarly, simply placing the equipment in a 'hazardous waste' container after it is placed in a paper bag is also incorrect as direct disposal into the designated container while wearing gloves is the proper protocol, making option D incorrect.
4. When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?
- A. After menopause, blood pressure readings in women are usually higher than those taken in men.
- B. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
- C. Blood pressure measurements in people who are overweight are usually higher than those of people who are at a normal weight.
- D. A teenager's blood pressure reading may be lower than that of an adult.
Correct answer: B
Rationale: When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.
5. A nurse caring for a client diagnosed with pertussis is ordered to maintain droplet precautions. Which of the following actions of the nurse upholds droplet precautions?
- A. Assign the client to stay in a negative-pressure room
- B. Use sterilized equipment when sharing between this client and another person with pertussis
- C. Wear a mask if coming within 3 feet of the client
- D. Both A and C
Correct answer: C
Rationale: When caring for a client requiring droplet precautions, it is essential for the nurse to wear a mask when within 3 feet of the client. This practice helps prevent the transmission of droplet particles that may be produced when the client coughs or sneezes. Assigning the client to a negative-pressure room is not typically necessary for droplet precautions unless specifically indicated for airborne precautions. Using sterilized equipment when sharing between clients with pertussis is important for infection control but does not directly relate to droplet precautions. Therefore, the correct action to uphold droplet precautions in this scenario is to wear a mask when coming within close proximity to the client.
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