NCLEX-RN : Ethics, Processing, and Care
Study concepts, example questions & explanations for NCLEX-RN
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Example Questions
Example Question #4 : Prevention And Risk Management
The oncology nurse cares for a patient receiving morphine sulfate 
Respiratory rate 8 breaths per minute
Blood pressure
Heart rate 65 beats per minute
Oxygen saturation 98%
Pain level 7 out of 10
Respiratory rate 8 breaths per minute
The nurse should be aware of potential complications of morphine sulfate, which can cause respiratory depression. Therefore, a respiratory rate of 8 breaths per minute should most concern the nurse (the normal limits are 12-18). The heart rate, blood pressure, and oxygen saturation are within normal limits. A patient on morphine sulfate should complain of pain, and although a pain level of 7 out of 10 requires attention, the respiratory depression takes priority.
Example Question #3 : Prevention And Risk Management
The nurse cares for a patient receiving an intravenous transfusion of gentamicin through an IV catheter in the patient’s left hand. Upon assessment, the nurse notices blanching and swelling at the site of the IV catheter, and the patient states he is feeling 8 out of 10 pain and it is “burning." In what order should the nurse perform the following tasks?
Aspirate the remaining fluid, stop the infusion, discontinue the catheter, and notify the primary care provider.
Discontinue the catheter, aspirate the remaining fluid, stop the infusion, and notify the primary care provider.
Stop the infusion, aspirate the remaining fluid, discontinue the catheter, and notify the primary care provider.
Notify the primary care provider, stop the infusion, aspirate the remaining fluid, and discontinue the catheter.
Stop the infusion, discontinue the catheter, notify the primary care provider, and aspirate the remaining fluid.
Stop the infusion, aspirate the remaining fluid, discontinue the catheter, and notify the primary care provider.
The nurse must recognize these signs and symptoms as potential extravasation, where a vesicant medication such as gentamicin, penicillin, dilantin, or chemotherapy has been given. It is essential to first stop the infusion and remove the insult. The nurse must then aspirate the remaining medication in the catheter to reduce the amount of exposure to the vesicant. The nurse can then remove and discontinue the catheter and notify the primary care provider.
Example Question #5 : Prevention And Risk Management
The nurse counsels patients at a community health fair about the importance of immunizations. Which of the following statements is most accurate concerning immunizations?
“Immunizations provide acquired immunity to some serious infectious diseases.”
“Immunizations will prevent all infectious diseases.”
“Immunizations provide natural immunity to some diseases.”
“Immunizations give your body the antibodies to fight infections.”
“Immunizations are risk-free and recommended by all healthcare providers.”
“Immunizations provide acquired immunity to some serious infectious diseases.”
The nurse should understand the mechanism of action, indications, and risks of immunizations as they do for all medications administered. Immunizations work by passively providing acquired immunity to specific diseases (such as influenza, hepatitis B, and varicella). They imitate a specific pathogen, influencing the patient’s body to produce antibodies that are capable of defending the body if it is exposed to the disease-causing element. The nurse should know that immunizations are specifically made for some diseases, and do not work for all diseases. Immunizations also come with minimal risks, and although they are widely given, are not universally prescribed. Patients should be educated with potential risks; some patients may experience fevers or rashes. Immunizations do not provide natural immunity to diseases; natural immunity is acquired by the patient when they contract a disease via exposure and the body produces its own antibodies. Immunizations do not provide antibodies to each disease.
Example Question #1 : Prevention And Risk Management
The community health nurse provides education about infectious diseases to college students in a dorm. Which of the following statements by the nurse would be appropriate?
“Hepatitis B is transmitted through ingestion of contaminated food and water.”
“Hepatitis A is transmitted through ingestion of contaminated food and water.”
Hepatitis D is transmitted through ingestion of contaminated food and water.”
“Hepatitis A is transmitted through infected blood and needles.”
“Hepatitis C is transmitted through ingestion of contaminated food and water.”
“Hepatitis A is transmitted through ingestion of contaminated food and water.”
Different types of viral hepatitis are transmitted through various routes. Hepatitis A is the only form that is transmitted through the fecal-oral route (contaminated food and water). Hepatitis B and D are transmitted through infected blood/needles as well as sex, and from infected mothers to newborns. Hepatitis C is transmitted through contaminated blood and needles. Recall that hepatitis D is an opportunistic infection, which requires hepatitis B infection.
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