NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A client is being transferred from a bed to a wheelchair. Which action is essential to maintain client safety in this situation?
- A. Position the wheelchair at the foot of the bed
- B. Maintain a space of at least 12 inches between the wheelchair and the bed
- C. Place the footplates in the lowest position before transferring the client
- D. Lock both wheels on the wheelchair before moving the client
Correct answer: D
Rationale: When transferring a client from a bed to a wheelchair, it is crucial to prioritize client safety. Locking both wheels on the wheelchair before moving the client is essential as it adds stability and prevents the wheelchair from moving unexpectedly during the transfer process. Placing the wheelchair at the foot of the bed allows for easier transfer, but ensuring the wheels are locked is more critical for safety. Maintaining a 12-inch space between the wheelchair and the bed is not as essential as ensuring wheel locks are engaged. While placing the footplates in the lowest position can enhance client comfort, it is not a safety measure that is as critical as securing the wheelchair by locking its wheels before the transfer.
2. What is the primary route of transmission of MRSA?
- A. Shared needles
- B. Hands of healthcare workers
- C. Items in the healthcare environment
- D. Blood transfusions
Correct answer: B
Rationale: The correct answer is 'Hands of healthcare workers.' MRSA is primarily transmitted via the unwashed hands of healthcare workers who can carry the Staphylococcus aureus bacterium from one patient to another. Shared needles, items in the healthcare environment, and blood transfusions are not the main routes of transmission for MRSA. Shared needles can transmit bloodborne pathogens, items in the healthcare environment can harbor bacteria but are not the primary mode for MRSA, and blood transfusions are not a common route for MRSA transmission.
3. Which acronym would BEST describe the procedure for assessing a patient that appears unconscious?
- A. WBC
- B. QRS
- C. XYZ
- D. ABC
Correct answer: D
Rationale: The correct answer is D, 'ABC.' The ABC method stands for Airway, Breathing, Circulation. When encountering an unconscious patient, it is crucial to first ensure their Airway is clear by performing the 'head tilt, chin lift' maneuver. Next, assess Breathing by observing for chest rise and fall, listening for breath sounds, and feeling for airflow. Finally, check for Circulation by assessing for a pulse. Choices A, B, and C ('WBC,' 'QRS,' 'XYZ') are incorrect as they do not represent the standard approach to assessing an unconscious patient.
4. 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.
5. Which of the following safety precautions should the nurse discuss when working with an immunocompromised client?
- A. Avoid canned foods and increase consumption of fresh fruits and vegetables
- B. Hand-wash utensils after use and allow them to air dry
- C. Only drink tap water that has been filtered or boiled before consumption
- D. Never eat meals prepared in restaurants
Correct answer: C
Rationale: The correct answer is to only drink tap water that has been filtered or boiled before consumption. Immunocompromised clients are susceptible to infections, so it is essential to take precautions to prevent exposure to harmful pathogens. Drinking tap water that has been filtered or boiled helps eliminate potential pathogens that could be harmful to the client's health. Choices A, B, and D do not directly address the issue of avoiding potential pathogens that could compromise the health of an immunocompromised client. Thus, they are incorrect. Hand-washing utensils, avoiding canned foods, and increasing fruit and vegetable consumption are good general hygiene practices but may not specifically address the needs of an immunocompromised client.
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