you see a patient lying on the loor of the bathroom you are not assigned to this patient what is the irst thing that you should do
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Nursing Elites

NCLEX-RN

NCLEX RN Exam Prep

1. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?

Correct answer: C

Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.

2. During a client interview, which of the following leading questions should the nurse avoid asking?

Correct answer: B

Rationale: The nurse should avoid asking leading questions during a client interview as they can influence the client's response. Option B is a leading question as it suggests an expected response from the client, potentially biasing the information provided. This can lead to inaccurate data collection and subsequent errors in diagnostic reasoning. Choices A, C, and D are open-ended questions that encourage the client to provide unbiased information and allow for a more comprehensive assessment.

3. Which principle of body mechanics may help to reduce the risk of a back injury?

Correct answer: C

Rationale: Proper body mechanics are crucial to prevent injuries, especially for professions involving lifting and moving objects. Keeping the back straight while lifting is essential to reduce the risk of back injuries as it helps maintain the spine's natural alignment and prevents excessive strain on the back muscles. Choosing choices A, B, and D would increase the risk of back injury. Maintaining a wide base of support provides stability, bending from the knees instead of the waist protects the lower back, and pushing or pulling objects reduces the strain on the back muscles, all contributing to preventing back injuries.

4. The Rule of Nines is used to:

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

5. A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?

Correct answer: C

Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.

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