NCLEX-RN : Procedures and Care

Study concepts, example questions & explanations for NCLEX-RN

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Example Questions

Example Question #41 : Procedures

Before administration, all plasma products must be tested for which of the following?

Possible Answers:

ABO compatibility

Rh compatibility and ABO compatibility

Rh compatibility

None of these are correct

Correct answer:

Rh compatibility and ABO compatibility

Explanation:

Before administration, plasma products must be checked for ABO compatibility and Rh compatibility.

ABO blood type does not have to be an exact match, but blood types must be compatible. An Rh positive individual, for example, is compatible with either Rh negative blood or positive blood, while an Rh negative individual is only compatible with Rh negative blood. 

Example Question #42 : Procedures

A nurse is performing standard cardiac auscultation on a 47 year old male with normal heart size.

Where would the nurse listen to evaluate the pulmonic valve?

Possible Answers:

The second right intercostal space

The first left intercostal space

The first right intercostal space

The second left intercostal space

Correct answer:

The second left intercostal space

Explanation:

The pulmonic valve can be auscultated to the left of the sternum at the second intercostal space. Auscultation at this space can aid in the identification of pulmonary murmurs such as pulmonary stenosis or regurgitation. The second right intercostal space is the location at which the nurse would be able to evaluate the aortic valve. The first intercostal space is not generally auscultated in a normal heart exam.

Example Question #43 : Procedures

A nurse is performing standard cardiac auscultation on a 47 year old male with normal heart size.

The nurse pauses to listen at the fifth intercostal space on the left mid-clavicular line. The nurse is evaluating which of the following?

Possible Answers:

The pulmonic valve

The aortic valve

The tricuspid valve

The mitral valve

Correct answer:

The mitral valve

Explanation:

The fifth intercostal space on the left mid-clavicular line is the best location from which to evaluate the mitral valve. The other heart structures are paired with locations as follows:

  • Aortic valve: the second intercostal space right of the sternum
  • Pulmonic valve: the second intercostal space left of the sternum
  • Tricuspid valve: the fourth intercostal space left of the sternum

Example Question #44 : Ethics, Processing, And Care

A nurse administers one unit of packed red blood cells. 4-6 hours later, what change can be expected in the patient's hemoglobin levels?

Possible Answers:

15% increase

20% increase

3% increase

5% decrease

Correct answer:

3% increase

Explanation:

A nurse should expect to see an approximately 3% increase in the recipient's hemoglobin 4-6 hours after the administration of one unit of packed red blood cells. 

Example Question #704 : Nclex

Which of the following has been removed from washed red blood cells?

Possible Answers:

All of these are correct

Antibodies

Platelets 

Plasma

Correct answer:

All of these are correct

Explanation:

Washed red blood cells are the product of blood that has been stripped of plasma, leukocytes, antibodies, cytokines, and platelets, in addition to any other blood proteins. 

Example Question #44 : Procedures

After thawing, fresh frozen plasma must be used within which of the following time frames?

Possible Answers:

Within 12 hours, if refrigerated

Within 24 hours, if refrigerated

Within 30 minutes (refrigeration is not advised)

Within two hours, if refrigerated

Correct answer:

Within 24 hours, if refrigerated

Explanation:

Whenever possible, fresh frozen plasma should be transfused immediately (or as soon as possible) after thawing. However, if this is not possible, it may be refrigerated for as long as 24 hours after thawing.

Example Question #45 : Procedures

Which of the following laboratory values is not reported in a basic metabolic profile (BMP).

Possible Answers:

Creatinine

Potassium

Phosphorus

Blood urea nitrogen (BUN)

Sodium

Correct answer:

Phosphorus

Explanation:

A BMP is a commonly ordered lab value set on patients. It checks commonly reported electrolytes in the body. It is also known as a Chem-7. It looks at: Sodium, potassium, carbon dioxide, bicarbonate, blood urea nitrogen (BUN), creatinine, and glucose. Phosphorous is not included in this laboratory order, and must be checked separately.

Example Question #46 : Procedures

A nurse is reviewing labs for a 63 year old female. Lipid testing revealed a total cholesterol of . This patient's cholesterol level would be defined as __________.

Possible Answers:

high risk

normal

moderate risk

low risk

Correct answer:

moderate risk

Explanation:

A total cholesterol over  is considered a risk factor for cardiovascular disease. A total cholesterol level of  is considered moderate risk, while a total cholesterol of over 240 mg/dL is considered a high risk for cardiovascular disease. This patient's total cholesterol is , which would place her in the moderate risk category.

Example Question #42 : Procedures And Care

Which of the following might be a sign of a transfusion reaction?

Possible Answers:

All of these are correct

Urticaria, itching, or swelling

Pallor or cyanosis

Myalgia, tingling, or numbness

Correct answer:

All of these are correct

Explanation:

Common signs of transfusion reaction include urticaria, itching, or swelling, pallor or cyanosis, anxiety, and myalgia, tingling, or numbness, in addition to diaphoresis, tachycardia, headache, and gastrointestinal distress.

Example Question #711 : Nclex

Droplet precautions are designed to stop the spread of infections diseases that travel through droplets. These droplets may land on the mucosa of the nose or mouth after a host sneezes or coughs. Which of the following conditions does not require the use of droplet precautions? 

Possible Answers:

Rubella

Influenza

Mumps

Varicella

Pertussis

Correct answer:

Varicella

Explanation:

Varicella requires airborne precautions. Staff caring for patients with varicella should be immune. One's immunity to varicella can be confirmed by a blood test.

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