NCLEX-RN
NCLEX RN Predictor Exam
1. Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.
- A. Client and Family
- B. Other nursing staff on the unit
- C. Security department
- D. Hospital administration
Correct answer: B
Rationale: Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.
2. Which of the following statements best describes substance P?
- A. Substance P decreases a client's sensitivity to pain
- B. Substance P levels are drawn before administration of narcotic analgesics
- C. Substance P is found in the brain and is responsible for pain control and management of depression
- D. Substance P is found in the dorsal horn of the spinal column
Correct answer: D
Rationale: Substance P is a neurotransmitter found in the brain and the dorsal horn of the spinal column, not just in the brain. It is associated with pain transmission and modulation. Substance P is known to cause inflammation, edema, and pain. While it plays a role in pain perception, it does not decrease a client's sensitivity to pain (Choice A), nor are its levels typically drawn before administering narcotic analgesics (Choice B). Although substance P is involved in pain control, it is not responsible for managing depression (Choice C). Therefore, the correct statement is that substance P is found in the dorsal horn of the spinal column.
3. Which of the following is an example of an environmental hazard that may put the healthcare professional at risk of injury?
- A. Loud noise from the hospital maintenance system
- B. Airborne powder containing latex
- C. Chemicals containing ethylene oxide
- D. All of the above
Correct answer: D
Rationale: Healthcare professionals, including nurses, are exposed to various environmental hazards that may negatively impact their physical or mental health. Hazards come in several forms, such as loud noise from hospital systems, which can damage hearing; airborne latex powder, leading to allergic reactions; and chemicals like ethylene oxide, a sterilizing agent that can cause cancer. Therefore, all the options listed pose risks to healthcare professionals, making 'All of the above' the correct answer. Choice A, loud noise, is a hazard that can affect hearing health. Choice B, airborne latex powder, can trigger allergic responses. Choice C, chemicals containing ethylene oxide, are hazardous and can lead to serious health issues. Each option represents a distinct environmental risk that healthcare professionals should be aware of and take precautions against.
4. A nurse is preparing to change a client's dressing for a burn wound on his foot. Which of the following interventions is appropriate for this process?
- A. Wash the wound with cleanser, rinse, and pat dry
- B. Bind the wound tightly, secure with tape, and elevate the foot
- C. Contact the physician after the dressing change is complete
- D. Provide analgesics for the client after the procedure
Correct answer: A
Rationale: When changing the dressing for a burn wound, it is essential to follow appropriate interventions to prevent infection, reduce pain, and support healing. In this scenario, after removing the old dressing, it is crucial to wash the wound gently with a suitable cleanser, rinse the area thoroughly, and then pat it dry. This process helps in maintaining cleanliness, reducing the risk of infection, and providing a conducive environment for healing. Binding the wound tightly (Choice B) can impede circulation and delay healing. Contacting the physician after the dressing change (Choice C) may be necessary in specific situations but is not a standard step in routine dressing changes. Providing analgesics after the procedure (Choice D) is important for pain management but is not directly related to the dressing change itself.
5. You are taking care of 5 patients today. One of your patients wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care problem must you deal with first?
- A. The water
- B. Help to the bathroom
- C. The chest pain
- D. The crying person
Correct answer: C
Rationale: The chest pain must be addressed immediately as it could indicate a serious condition like a heart attack. Treating chest pain is a top priority in healthcare settings due to the potential life-threatening nature of the symptom. Providing immediate attention to chest pain ensures prompt assessment, diagnosis, and intervention, which are crucial for patient safety and well-being. Addressing the other needs, such as providing water, assisting with bathroom needs, or emotional support, can follow once the urgent issue of chest pain has been managed. While the other patient concerns are important, the critical nature of chest pain requires immediate action to rule out severe cardiac events and provide appropriate care.
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