Blog about quiz / question and answer NCLEX (National Council Licensure Examination) For Nursing Student, Example Question NCLEX RN and NCLEX PN. Exam for Nurse
1. A nurse is assisting in preparing a client for a blood transfusion. Which of the following missing items would be most important for the nurse to retrieve or obtain in order to proceed with client identification?
A. Identification (ID) bracelet
B. Social security number
C. Client address
D. Medical record number
Answer: A. Identification (ID) bracelet
Rationale: The identification bracelet that is placed on the client at admission is the most important item for proper client identification. The ID bracelet contains the client’s name, age, physician name, room number, and a hospital and/or medical record identification number. It contains the same information that is present on the client’s addressograph card, which is stamped on all client requisitions. The social security number and address are irrelevant for the procedure described. The medical record number would most likely be present on the client’s ID bracelet.
Test-Taking Strategy: Use the process of elimination and focus on the issue—client identification. Begin to answer the question by eliminating options 2 and 3 first as incorrect. Choose option 1 over option 4 because it is the umbrella (global) option. Review the procedure for administering a blood transfusion if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Fundamental Skills
Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 449.
2. A client requiring upcoming surgery is extremely anxious about the need for possible blood transfusion during or after surgery and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client do which of the following as the most effective way to eliminate this risk?
A. Take iron supplements before surgery to boost hemoglobin levels
B. Request that any donated blood be screened twice by the blood bank
C. Ask a friend or family member to donate blood ahead of time
D. Donate autologous blood before the surgery
Answer: D. Donate autologous blood before the surgery
Rationale: Donating autologous blood to be reinfused as needed during or after surgery eliminates the risk of cross-infection from contaminated blood. The next most effective way to reduce the risk of contamination is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia, but are not most helpful in replacing blood lost during the surgery.
Test-Taking Strategy: Use the process of elimination. Note the key words most effective. This tells you that more than one or all of the options may be partially or totally correct. Noting the key word autologous in option 4 will direct you to this option. Review disease transmission and blood donation procedures if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Fundamental Skills
Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, pp. 448-449.
3. A nurse is collecting initial data on a newborn in the delivery room. Which of the following would the nurse expect to note when examining the umbilical cord of the newborn?
A. Two arteries and one vein
B. Two veins and one artery
C. One artery and one vein
D. Two arteries and two veins
Answer: A. Two arteries and one vein
Rationale: The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo.
Test-Taking Strategy: Focus on the issue—a normal umbilical cord. Recall the anatomy of the umbilical cord to help you answer the question. Review this anatomy if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Intrapartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 522.
4. A pregnant client is seen in the health care clinic and is complaining of morning sickness. The client asks the nurse about measures to relieve this sick feeling. The appropriate suggestion to the client is:
A. Eat a high-carbohydrate diet
B. Eat a high-fat diet
C. Eat dry crackers before arising
D. Increase fluids with meals
Answer: C. Eat dry crackers before arising
Rationale: Some strategies for decreasing morning sickness are keeping crackers, Melba toast, or dry cereal at the bedside to eat before getting up in the morning; eating smaller, more frequent meals; decreasing fat intake; and consuming adequate fluid between meals. Options 1, 2, and 4 are not appropriate measures to relieve morning sickness.
Test-Taking Strategy: Use the process of elimination. Note the relationship between the client’s complaint, morning sickness, and the correct option, to eat dry crackers before arising. Review the measures to relieve morning sickness if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Maternity/Antepartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 275.
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