NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. 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.
2. A nurse caring for a client diagnosed with pertussis is ordered to maintain droplet precautions. Which of the following actions of the nurse upholds droplet precautions?
- A. Assign the client to stay in a negative-pressure room
- B. Use sterilized equipment when sharing between this client and another person with pertussis
- C. Wear a mask if coming within 3 feet of the client
- D. Both A and C
Correct answer: C
Rationale: When caring for a client requiring droplet precautions, it is essential for the nurse to wear a mask when within 3 feet of the client. This practice helps prevent the transmission of droplet particles that may be produced when the client coughs or sneezes. Assigning the client to a negative-pressure room is not typically necessary for droplet precautions unless specifically indicated for airborne precautions. Using sterilized equipment when sharing between clients with pertussis is important for infection control but does not directly relate to droplet precautions. Therefore, the correct action to uphold droplet precautions in this scenario is to wear a mask when coming within close proximity to the client.
3. A client is receiving high-dose brachytherapy as a form of cancer treatment. What type of teaching must the nurse include when educating this client about safety?
- A. The client must remain in isolation under airborne precautions
- B. The client should stay in a private room at the hospital
- C. The client may need to limit visits from friends and family
- D. Both B and C
Correct answer: D
Rationale: A client undergoing high-dose brachytherapy has a radiation implant placed for cancer treatment. To ensure safety, the client should be in a private hospital room to prevent radiation exposure to others. Limiting visits from friends and family is necessary to prevent overexposure. Option A is incorrect as isolation under airborne precautions is not required for brachytherapy. Option B and C are the correct choices as they focus on minimizing radiation exposure to others, ensuring safety during treatment.
4. When should you wear gloves?
- A. preparing infant formula for a newborn baby
- B. transferring breast milk into a baby bottle
- C. knocking on a patient's door
- D. opening a patient's door
Correct answer: B
Rationale: You must wear gloves when transferring breast milk into a baby bottle because breast milk is considered a bodily fluid. It is essential to avoid direct contact to prevent contamination. When preparing infant formula, gloves are not required as formula is not a bodily fluid. Knocking on or opening a patient's door does not involve direct contact with bodily fluids, so gloves are unnecessary in those situations.
5. A client is suspected of having carbon monoxide poisoning. Which of the following symptoms are associated with this condition?
- A. Red rash across the trunk and extremities
- B. Nausea, vomiting, seizures
- C. Flushing of the face and neck
- D. Abdominal pain radiating to the back
Correct answer: B
Rationale: The correct answer is 'Nausea, vomiting, seizures.' Carbon monoxide poisoning can present with symptoms such as headache, dizziness, weakness, nausea, vomiting, and confusion. Severe cases can progress to seizures, coma, and even death. It is crucial for healthcare providers to recognize these symptoms promptly to initiate appropriate treatment. Choices A, C, and D are incorrect because a red rash, flushing of the face and neck, and abdominal pain radiating to the back are not typically associated with carbon monoxide poisoning. It is essential to be aware of the common manifestations of carbon monoxide poisoning to ensure timely intervention and prevent adverse outcomes.
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