NCLEX-RN
NCLEX RN Exam Prep
1. You are ready to wash your patient's face. You would start by washing what area of the face?
- A. The forehead
- B. The eyes
- C. The ears
- D. The cheeks
Correct answer: B
Rationale: When washing a patient's face, it is essential to start by cleaning the eyes. The eye area is considered the priority because moving from an area that can potentially be infected to areas of the face and body that are least able to become infected with a washcloth helps prevent the spread of germs. Washing the forehead, ears, or cheeks before the eyes may risk transferring bacteria to a more sensitive area like the eyes, which could lead to infections or other complications. Therefore, starting with the eyes ensures proper hygiene and reduces the risk of introducing harmful microorganisms to the patient's face.
2. Following hospitalization for congestive heart failure, a client is discharged. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
- A. High Fowler's
- B. Supine
- C. Left lateral
- D. Low Fowler's
Correct answer: A
Rationale: The correct answer is High Fowler's. Sitting in a chair or resting in a bed in the high Fowler's position helps decrease the cardiac workload and facilitates breathing in clients with congestive heart failure. This position helps reduce venous return and increases lung expansion, improving oxygenation. The supine position (choice B) may lead to increased pressure on the heart and lungs, making it less suitable for these clients. The left lateral position (choice C) is not as effective as High Fowler's in reducing cardiac workload and improving breathing. Low Fowler's position (choice D) does not provide the same benefits as the High Fowler's position for clients with congestive heart failure.
3. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?
- A. "Are you of the Christian faith?"?
- B. "Do you want to see a medicine man?"?
- C. "How often do you seek help from medical providers?"?
- D. "What cultural or spiritual beliefs are important to you?"?
Correct answer: D
Rationale: The nurse needs to assess the cultural beliefs and practices of the patient and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication. Therefore, the most appropriate question to initiate an assessment of cultural beliefs with an older American Indian patient is "What cultural or spiritual beliefs are important to you?"? This question shows respect for the patient's beliefs and encourages them to share relevant information. Asking if they are of the Christian faith does not promote open communication and may not reflect the patient's actual beliefs. While some American Indians may seek assistance from a medicine man or shaman, it is not appropriate to make assumptions without direct input from the patient. Asking how often they seek help from medical providers is not directly related to understanding their cultural beliefs and may not provide relevant insights for culturally competent care.
4. A healthcare professional is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?
- A. Cephalic
- B. Median cubital
- C. Basilic
- D. All of the above
Correct answer: D
Rationale: The correct answer is 'All of the above.' All three of these veins - the cephalic, median cubital, and basilic veins - are located in the antecubital space, which is the area in front of the elbow on the arm. The cephalic vein runs along the outer side of the arm, the basilic vein runs along the inner side of the arm, and the median cubital vein is a connecting vein between the cephalic and basilic veins. Therefore, all three veins can be accessed when drawing blood from the antecubital space. Choices A, B, and C are incorrect because each of these veins individually can be found in the antecubital space.
5. What is the proper personal protective equipment necessary for collecting a sputum specimen?
- A. Gloves and face mask
- B. Level Three Biocontainment uniforms
- C. Eye protection and shoe covers
- D. Splash shield and face mask
Correct answer: A
Rationale: When collecting a sputum specimen, it is crucial to protect against potential airborne droplets that may spread disease. The best personal protective equipment for this task includes gloves and a face mask. Gloves help prevent the spread of contaminants through hand contact, while a face mask protects the respiratory tract from inhaling infectious agents. Choice B, Level Three Biocontainment uniforms, is excessive and unnecessary for routine sputum specimen collection. Choice C, eye protection and shoe covers, does not address the specific risks associated with sputum collection. Choice D, splash shield and face mask, provides additional protection that is not typically required for sputum specimen collection, making it less appropriate than gloves and a face mask.
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