you see a sign over mary jones bed when you arrive at 7 am to begin your day shift the sign says npo ms jones is on a regular diet the patient asks fo

NCLEX-RN

NCLEX RN Exam Prep

1. You see a sign over Mary Jones' bed when you arrive at 7 am to begin your day shift. The sign says, 'NPO'. Ms. Jones is on a regular diet. The patient asks for milk and some crackers. You _____________.

A. can give her the milk but not the crackers
B. can give her both the milk and the crackers
C. can give her the crackers but not the milk
D. cannot give her anything to eat or drink

Correct answer: D

Rationale: The correct answer is that you cannot give her anything to eat or drink. 'NPO' is the standard abbreviation for 'nothing by mouth,' indicating that the patient should not consume any food or liquids. It is crucial to adhere to this restriction to prevent any potential harm or complications in the patient's condition. Choices A, B, and C are incorrect because 'NPO' clearly specifies that the patient should not have anything to eat or drink, including milk and crackers. Providing these items could lead to adverse effects, so it is essential to follow the 'NPO' directive strictly.

2. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?

A. Assessing the patient for jaundice
B. Providing oral hygiene after a meal
C. Palpating the abdomen for distention
D. Assisting the patient to choose the diet

Correct answer: B

Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.

3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

A. Angina at rest
B. Thrombus formation
C. Dizziness
D. Falling blood pressure

Correct answer: B

Rationale: Thrombus formation is a critical complication of cardiac catheterization that the nurse should monitor for in the initial 24 hours after the procedure. A thrombus can form in the blood vessels, obstructing blood flow and potentially leading to serious consequences such as embolism or organ ischemia. While angina at rest, dizziness, and falling blood pressure are potential complications following cardiac catheterization, they are not typically associated with the immediate post-procedural period. Monitoring for thrombus formation is essential to ensure early detection and intervention, which can prevent serious complications.

4. Which is the most effective action for controlling the spread of infection?

A. Thorough hand hygiene
B. Wearing gloves and masks when providing direct client care
C. Implementing appropriate isolation precautions
D. Administering broad-spectrum prophylactic antibiotics

Correct answer: A

Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.

5. To properly read a meniscus,

A. hold the measuring device at eye level and read the bottom of the curve of the liquid level
B. hold the measuring device at eye level and read the top of the curve of the liquid level where the liquid adheres to the walls of the container.
C. hold the measuring device at table level and, looking down into the measuring device, read the bottom of the curve of the liquid level.
D. hold the measuring device at table level and, looking down into the measuring device, read the top of the curve of the liquid level.

Correct answer: A

Rationale: To properly read a meniscus, it is essential to hold the measuring device at eye level to avoid parallax error. Reading the bottom of the curve of the liquid level is correct because the meniscus is the concave or convex curve at the liquid's surface. Choice B is incorrect because reading the top of the curve where the liquid adheres to the walls of the container can lead to inaccurate measurements. Choices C and D are incorrect as they suggest holding the device at table level, which can introduce parallax error and result in an incorrect reading.