NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A client has become combative and is attempting to pull out his IV and take off his surgical dressings. The nurse receives an order to apply wrist restraints. Which action of the nurse signifies that restraints are being used safely?
- A. The nurse ties the restraints in a square knot to prevent the client from untying them
- B. The restraints are attached to a movable portion of the bed
- C. The padded side of the restraint is applied next to the skin of the wrist
- D. The nurse assesses the client's distal circulation every 24 hours
Correct answer: C
Rationale: Restraint use must prioritize the safety of the client. When applying restraints around the wrists, the padded side should be placed against the skin to help prevent skin breakdown. Additionally, restraints should be secured in quick-release knots to ensure they can be removed rapidly in case of an emergency. Choice A is incorrect as restraints should not be tied in a way that could prevent quick removal. Choice B is incorrect because restraints should not be attached to a movable part of the bed to avoid unintentional movement. Choice D is incorrect as assessing distal circulation is important but is not directly related to the safe application of restraints.
2. Which of the following situations indicates the need to file an incident report?
- A. The neon sign directing parking for visitors has burned out
- B. A nurse must send a syringe pump to maintenance for annual service
- C. A client's blood pressure dropped to 90/55 after receiving a dose of morphine
- D. A client's spouse becomes angry and is asked to leave the premises
Correct answer: D
Rationale: An incident report is necessary for documenting unexpected events that occur in a healthcare setting. Situations that warrant filing an incident report include client accidents, medication errors, security problems, or disruptive behaviors that involve clients, families, or visitors. In this scenario, when a client's spouse displays disruptive behavior and is asked to leave the premises, it is essential to document this incident to ensure a record of the event and its resolution. Choices A, B, and C do not involve disruptive behavior or safety concerns that would require an incident report to be filed.
3. Which of the following may represent an upper airway obstruction?
- A. Retractions
- B. Elongated expiratory phase
- C. Stridor
- D. Expiratory wheezing
Correct answer: C
Rationale: Stridor is the sound produced by turbulent airflow through a partially obstructed upper airway. It is a classic sign of upper airway obstruction. While an elongated expiratory phase may indicate lower airway obstruction, stridor specifically points to an upper airway issue. Retractions are also often seen in upper airway obstruction due to the increased effort of breathing. Expiratory wheezing, on the other hand, is more indicative of lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD).
4. While performing CPR, a healthcare provider encounters a client with a large amount of thick chest hair when preparing to use an automated external defibrillator (AED). What is the next appropriate action for the healthcare provider?
- A. Apply the pads to the chest and provide a shock
- B. Wipe the client's chest down with a towel before applying the pads
- C. Shave the client's chest to remove the hair
- D. Do not use the AED
Correct answer: C
Rationale: When using an AED, it is crucial for the pads to have good contact with the skin to effectively deliver an electrical shock. While AED pads can adhere to a client's chest even with some hair, thick chest hair can hinder proper current conduction. In such cases, it is recommended to shave the area of the chest where the pads will be applied. Most AED kits include a razor for this purpose. The healthcare provider should act promptly to minimize delays in defibrillation. Option A is incorrect because it may lead to ineffective treatment due to poor pad adherence. Option B is not the best course of action as wiping the chest may not resolve the issue of poor pad contact. Option D is incorrect as not using the AED could jeopardize the client's chance of survival in a cardiac emergency.
5. When dismissing a 5-year-old boy from the pediatrics unit, what type of seat belt restraint should the child wear as the parents drive the car to the front door of the hospital?
- A. A 5-point restraint in the back seat, facing backward
- B. A booster seat with a lap and shoulder belt in the back seat
- C. A lap belt in the back seat
- D. A lap and shoulder belt in the front seat
Correct answer: B
Rationale: A 5-year-old child riding in a car should use a restraint system for safety. The Centers for Disease Control and Prevention recommend that children under 13 years should not ride in the front seat of a car due to safety concerns. For a 5-year-old child, a booster seat with a lap and shoulder belt in the back seat is the most appropriate choice. This setup ensures proper protection and restraint for the child's size and age. Choice A is incorrect because a 5-point restraint system facing backward is not suitable for a 5-year-old child in a car. Choice C is incorrect as a lap belt alone does not provide adequate protection for a child of this age. Choice D is incorrect as children should not be seated in the front seat, especially at this young age.
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