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. Who is the center of care?
- A. The doctor
- B. The administrator
- C. The patient
- D. The nurse
Correct answer: C
Rationale: The PATIENT is the center of care and the core of the healthcare team. The PATIENT holds the utmost importance within the healthcare setting. Healthcare professionals collaborate as a team to effectively address the needs of the patient. The primary focus should always be on the patient, who plays a crucial role in decision-making. While other healthcare team members, such as doctors, nurses, and administrators, play vital roles, the patient remains the central figure. The patient has the fundamental right to receive quality care from all members of the healthcare team.
3. Which of the following is a fat-soluble vitamin?
- A. Vitamin C
- B. Vitamin D
- C. Vitamin B-6
- D. Riboflavin
Correct answer: B
Rationale: The correct answer is Vitamin D. Fat-soluble vitamins are those that can be stored in the body, allowing excess amounts to be stored for later use. While this storage ability can help prevent deficiencies, it also poses a risk of toxicity. The fat-soluble vitamins are A, E, D, and K. Choice A, Vitamin C, is water-soluble, not fat-soluble. Choice C, Vitamin B-6, and Choice D, Riboflavin, are also water-soluble vitamins and not fat-soluble.
4. An Asian-American woman is experiencing diarrhea, which is believed to be "cold"? or "yin."? What should the nurse recognize that the woman may likely try to treat it?
- A. Foods that are "hot"? or "yang"?
- B. Readings and Eastern medicine meditations
- C. High doses of medicines believed to be "cold"?
- D. No treatment because diarrhea is an expected part of life.
Correct answer: A
Rationale: In this scenario, the Asian-American woman is believed to be experiencing diarrhea due to a "cold"? or "yin"? imbalance. According to the yin/yang theory, yang represents heat and yin represents cold. Therefore, to balance the cold nature of the diarrhea, the woman may try to treat it by consuming foods that are considered "hot"? or "yang"?. This aligns with the concept that cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. Choices B, C, and D do not align with the yin/yang theory and are not relevant to addressing the imbalance associated with the cold nature of the diarrhea.
5. What technique would the nurse use to accurately assess a rectal temperature in an adult?
- A. Use a lubricated blunt tip thermometer.
- B. Insert the thermometer 2 to 3 inches into the rectum.
- C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
- D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
Correct answer: A
Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.
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