NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Which of the following diseases would require the nurse to wear an N95 respirator as part of personal protective equipment?
- A. Human immunodeficiency virus
- B. Clostridium difficile enterocolitis
- C. Vancomycin-resistant enterococcus
- D. Measles
Correct answer: D
Rationale: Infections that require airborne precautions necessitate the use of an N95 respirator, a type of mask that filters particles that are 5 micrograms or smaller. Illnesses that require airborne precautions include Measles, Varicella, Severe Acute Respiratory Syndrome (SARS), and tuberculosis. Measles is a highly contagious airborne disease caused by a virus. It can spread through respiratory droplets when an infected person coughs or sneezes. Wearing an N95 respirator helps prevent the nurse from inhaling these infectious particles. Human immunodeficiency virus, Clostridium difficile enterocolitis, and Vancomycin-resistant enterococcus do not require the use of an N95 respirator as they are not transmitted through the air but have other modes of transmission.
2. What is the proper personal protective equipment necessary for collecting a sputum specimen?
- A. Gloves and face mask
- B. Level Three Biocontainment uniforms
- C. Eye protection and shoe covers
- D. Splash shield and face mask
Correct answer: A
Rationale: When collecting a sputum specimen, it is crucial to protect against potential airborne droplets that may spread disease. The best personal protective equipment for this task includes gloves and a face mask. Gloves help prevent the spread of contaminants through hand contact, while a face mask protects the respiratory tract from inhaling infectious agents. Choice B, Level Three Biocontainment uniforms, is excessive and unnecessary for routine sputum specimen collection. Choice C, eye protection and shoe covers, does not address the specific risks associated with sputum collection. Choice D, splash shield and face mask, provides additional protection that is not typically required for sputum specimen collection, making it less appropriate than gloves and a face mask.
3. A client has just started a transfusion of packed red blood cells that a physician ordered. Which of the following signs may indicate a transfusion reaction?
- A. The client suddenly complains of back pain and has chills
- B. The client develops dependent edema in the extremities
- C. The client has a seizure
- D. The client's heart rate drops to 60 bpm
Correct answer: A
Rationale: The correct answer is when the client suddenly complains of back pain and has chills. Signs of a transfusion reaction include back pain, chills, dizziness, increased temperature, and blood in the urine. These signs indicate a possible adverse reaction to the blood transfusion. Dependent edema in the extremities is not typically associated with a transfusion reaction. A seizure is not a common sign of a transfusion reaction unless it is due to severe complications. A decrease in heart rate to 60 bpm is not a typical sign of a transfusion reaction, but rather bradycardia may indicate other underlying conditions or medications.
4. The Rule of Nines is used to:
- A. determine the amount of the body surface that has been burned
- B. assess the level of oxygen saturation in a body that has been burned.
- C. determine the level of tissue damage that has occurred in a burn.
- D. None of the above.
Correct answer: A
Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.
5. The NFPA diamond has four colors. The blue diamond:
- A. indicates hazards to health.
- B. designates that it is safe to use water to put out this type of fire.
- C. indicates that ice is necessary to treat an injury with this type of chemical.
- D. indicates that the chemical may be incinerated upon disposal.
Correct answer: A
Rationale: The National Fire Protection Agency (NFPA) uses a safety diamond to communicate the level of threat posed by a specific chemical. The blue diamond in the NFPA diamond system signifies potential health hazards associated with the use of that chemical. Choice B is incorrect because the blue diamond does not indicate anything about using water to extinguish fires. Choice C is incorrect as the NFPA diamond does not provide information on treating injuries. Choice D is also incorrect as the blue diamond does not suggest incineration upon disposal; it pertains to health hazards.
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