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Nursing Elites

NCLEX-RN

NCLEX RN Exam Prep

1. Nursing care plans are _______________?

Correct answer: B

Rationale: Nursing care plans are comprehensive documents created by registered nurses to outline individualized care for patients. These plans serve as guidelines for all members of the nursing team, including nursing assistants, to ensure consistent and quality care. Choice A is incorrect as CNAs typically assist in implementing the care plan rather than creating it. Choice C is incorrect as nursing care plans are utilized by all members of the nursing team, not exclusive to only nurses. Choice D is incorrect as nursing assistants also utilize nursing care plans to provide patient care effectively.

2. What is the primary purpose of emergency planning?

Correct answer: D

Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.

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?

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. Who is the center of care?

Correct answer: C

Rationale: The PATIENT is the center of care and the core of the healthcare team. The PATIENT holds the utmost importance within the healthcare setting. Healthcare professionals collaborate as a team to effectively address the needs of the patient. The primary focus should always be on the patient, who plays a crucial role in decision-making. While other healthcare team members, such as doctors, nurses, and administrators, play vital roles, the patient remains the central figure. The patient has the fundamental right to receive quality care from all members of the healthcare team.

5. The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene?

Correct answer: A

Rationale: The correct answer is to percuss twice over each area, not once. This technique helps ensure a more accurate assessment. Striking with the fingertip instead of the finger pad is correct because the tip of the finger produces clearer sounds. Using the wrist to make the strikes instead of the arm is appropriate as it allows for more controlled and precise percussion. Quickly lifting the striking finger after each stroke is also correct to prevent damping off vibrations. Therefore, percussing once over each area (Choice A) is incorrect as it does not follow the standard percussion technique.

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