NCLEX RN Questions Nursing Fundamentals

NCLEX RN Questions Nursing Fundamentals Related

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Room Number Patient and Diagnosis
43-year-old male receiving intravenous antibiotics for Lyme disease
Contact
17 -year-old female receiving antiviral for varicella.
Airborne and Contact
3
89-year-old male diagnosed with Mumps.
Droplet
4
33-year-old male newly diagnosed with human immunodeficiency virus (HIV).
Standard

The infection control nurse is reviewing client room assignments. Which room assignment requires modification? Room Number Patient and Diagnosis: 1. 43-year-old male receiving intravenous antibiotics for Lyme disease - Contact; 2. 17-year-old female receiving antiviral for varicella - Airborne and Contact; 3. 89-year-old male diagnosed with Mumps - Droplet; 4. 33-year-old male newly diagnosed with human immunodeficiency virus (HIV) - Standard

  • A. Room 1
  • B. Room 2
  • C. Room 3
  • D. Room 4
Correct Answer: A

Rationale: Lyme disease is not typically transmitted person-to-person and does not require contact precautions; standard precautions are sufficient. Varicella requires airborne and contact precautions, mumps requires droplet precautions, and HIV requires standard precautions, making Room 1's assignment incorrect.

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The nurse is assessing a client's peripheral vascular access device. The assessment shows that the site is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Which of the following complications is the client experiencing?

  • A. Occlusion
  • B. Infiltration
  • C. Phlebitis
  • D. Air embolism
Correct Answer: C

Rationale: Redness, warmth, pain, and edema indicate phlebitis, vein inflammation. Occlusion blocks flow, infiltration involves fluid leakage, and air embolism is unrelated.

The charge nurse is observing infection control practices in the nursing unit. Which observation by the charge nurse requires follow-up? Select all that apply.

  • A. Soiled linens are placed on the floor during a bed bath and linen change.
  • B. A disposable blood pressure cuff is used for a client on contact precautions.
  • C. Disposable dishes are placed in the room for a client on droplet precautions.
  • D. Reusable eye protection is cleaned and disinfected after each client encounter.
  • E. A surgical hand scrub is performed with the hands lower than the elbows.
  • F. Gloves are doffed last while removing personal protective equipment (PPE).
Correct Answer: A,E,F

Rationale: Soiled linens on the floor risk contamination, hands should be higher than elbows during surgical scrub, and gloves should be doffed first to prevent contamination.

The nurse is observing a student nurse feed a client requiring aspiration precautions. The nurse should intervene if the student

  • A. Asks the client to remain sitting upright for at least 30 to 60 minutes after a meal.
  • B. Reminds the client to tilt their head backward when eating and drinking.
  • C. Avoids mixing foods of different textures in the same mouthful.
  • D. Places salt and pepper on the client's food at their request.
Correct Answer: B

Rationale: Tilting the head backward increases aspiration risk. Upright positioning, avoiding mixed textures, and seasoning food are appropriate.

The nurse is educating the parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding?

  • A. I should tell my child to ride their bike against the traffic pattern.
  • B. I should instruct my child to walk their bike through busy intersection crosswalks.
  • C. Wearing a helmet is only necessary when my child is riding near a busy intersection.
  • D. My child can ride their bike barefoot as long as it's short distances.
Correct Answer: B

Rationale: Walking the bike through busy intersections enhances safety. Riding against traffic, optional helmet use, and barefoot riding are unsafe.

The nurse is prioritizing caring for four assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, which of the clients should the nurse follow up with first?

  • A. P: 109; R: 26; BP: 110/70 mmHg
  • B. P: 90; R: 12; BP: 99/54 mmHg
  • C. P: 100; R: 18; BP: 161/98 mmHg
  • D. P: 88; R: 14; BP: 166/52 mmHg
Correct Answer: B

Rationale: BP 99/54 mmHg indicates hypotension, requiring immediate follow-up. Tachycardia/tachypnea, hypertension, and wide pulse pressure are concerning but less urgent.

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