NCLEX RN Question Bank Free
Question 1 of 5.
The nurse is preparing to perform a Mantoux tuberculin skin test. Which interventions apply to the administration of this test? Select all that apply.
A. Explain the procedure to the client.
B. Obtain a 3-mL syringe with a 1/2-inch needle for the injection.
C. Mark the test area to locate it for reading 48 to 72 hours after injection.
D. Bunch up the skin and insert the needle with the needle bevel facing downward.
E. Cleanse the injection site on the lower dorsal surface of the forearm with alcohol and allow it to dry.
F. Ask the client about a history of receiving a positive purified protein derivative (PPD) reaction.
Explanation: The nurse should always explain the procedure to the client and then assess him or her for a history of a PPD reaction. The test should not be administered if the client has such a history. The nurse should use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut, and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.
Question 2 of 5.
Select the member of the multidisciplinary team that you would most likely collaborate with when the client can benefit from the use of adaptive devices for cutting food?
A. The physical therapist
B. The occupational therapist
C. The dietician
D. The podiatrist
Explanation: An occupational therapist specializes in helping clients use adaptive devices to perform activities of daily living, such as cutting food, making them the most appropriate team member for this need.
Question 3 of 5.
The Joint Commission on the Accreditation of Healthcare Organizations mandates standardized 'hand off' change of shift reporting. Which of the following is a standardized 'hand off' change of shift reporting system that you may want to consider for implementation on your nursing care unit?
A. The Four P's
B. UBAR
C. ISBAR
D. MAUMAR
Explanation: ISBAR is a standardized hand-off reporting system (Introduction, Situation, Background, Assessment, Recommendation) recommended by The Joint Commission for effective communication during shift changes.
Question 4 of 5.
Which of the following is NOT an essential minimal component of the teaching that occurs prior to getting an informed consent?
A. The purpose of the proposed treatment or procedure
B. The expected outcomes of the proposed treatment or procedure
C. Who will perform the treatment or procedure
D. When the procedure or treatment will be done
Explanation: Essential components of informed consent include the purpose , expected outcomes , and who will perform the procedure . The specific timing is not a required minimal component.
Question 5 of 5.
The primary distinguishing characteristic of risk management when compared and contrasted to performance improvement is that risk management activities focus on:
A. Historical data and performance improvement activities focus on current data.
B. Current data and performance improvement activities focus on historical data.
C. Decreasing financial liability and performance improvement activities focus on process improvements.
D. Decreasing falls and performance improvement activities focus on process improvements.
Explanation: Risk management focuses on decreasing financial liability by mitigating risks, while performance improvement focuses on enhancing processes and outcomes.