NCLEX-RN : Care

Study concepts, example questions & explanations for NCLEX-RN

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Example Questions

Example Question #1 : Prevention And Risk Management

The nurse is preparing to enter a contact-isolation room where she will preform a bed bath. It is reasonable to expect her gloves to become soiled at some point during the administration of care. While preparing to enter, the nurse __________.

Possible Answers:

wears a single pair of sterile gloves

wears two pairs of sterile gloves

wears a pair of clean gloves under a pair of sterile gloves

wears two pairs of clean gloves

wears a single pair of clean gloves

Correct answer:

wears a single pair of clean gloves

Explanation:

In the interest of infection control, it is best to only wear one pair of gloves at a time. While giving a bed bath, it is not necessary to wear sterile gloves. If the gloves become saturated, remove the gloves, perform hand hygiene, and wear a new pair. 

Example Question #131 : Procedures And Care

The emergency room nurse cares for a patient reporting pain in the lower back. The client tells the nurse, “I have taken three 500-milligram tablets of acetaminophen every three hours since last night, but the pain hasn’t gone away.” Which of the following clinical manifestations in the patient most concerns the nurse?

Possible Answers:

Ringing in the ears

International normalized ratio (INR) of 1.1

alanine transaminase (ALT): 

Higher blood pressure

Diarrhea and loose stools

Correct answer:

alanine transaminase (ALT): 

Explanation:

The nurse should be concerned about acetaminophen toxicity, as the recommended daily dose of acetaminophen is 4 grams for adults, and this patient has exceeded this amount. (Three 500-milligram tablets every three hours is equal to 12 grams in a 24-hour period.) Acetaminophen toxicity may manifest with nausea and vomiting in the first 24 hours and right upper quadrant abdominal pain afterwards due to liver damage. Tinnitus, high blood pressure, and diarrhea are not symptoms of acetaminophen poisoning. An international normalized ratio (INR) of 1.1 is within normal limits, but may be trending upwards, as the liver is responsible for producing clotting factors. Liver function tests should always be done when acetaminophen poisoning is suspected; aspartate transaminase (AST) and alanine transaminase (ALT) values above  suggest hepatic damage.

Example Question #81 : Care

The oncology nurse cares for a patient receiving morphine sulfate  IV push q4h for pain. Which of the following most concerns the nurse?

Possible Answers:

Blood pressure

 

Pain level 7 out of 10

Heart rate 65 beats per minute

Respiratory rate 8 breaths per minute

Oxygen saturation 98%

Correct answer:

Respiratory rate 8 breaths per minute

Explanation:

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?

Possible Answers:

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.

Correct answer:

Stop the infusion, aspirate the remaining fluid, discontinue the catheter, and notify the primary care provider.

Explanation:

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?

Possible Answers:

“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.”

Correct answer:

“Immunizations provide acquired immunity to some serious infectious diseases.”

Explanation:

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 #82 : Care

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?

Possible Answers:

“Hepatitis A is transmitted through ingestion of contaminated food and water.”

“Hepatitis C is transmitted through ingestion of contaminated food and water.”

“Hepatitis A is transmitted through infected blood and needles.”

“Hepatitis B is transmitted through ingestion of contaminated food and water.”

Hepatitis D is transmitted through ingestion of contaminated food and water.”

Correct answer:

“Hepatitis A is transmitted through ingestion of contaminated food and water.”

Explanation:

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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