a nurse is performing cpr on a client when a co worker brings an automated external deibrillator aed the nurse prepares to apply the patches to the c
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Nursing Elites

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?

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. When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?

Correct answer: B

Rationale: When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.

3. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?

Correct answer: D

Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.

4. Which bloodborne pathogen is the most virulent? (Choose the BEST answer.)

Correct answer: A

Rationale: The correct answer is HCV (Hepatitis C Virus). Hepatitis C is considered the most virulent bloodborne pathogen, being 100 times more virulent than Hepatitis B. HPV (Human Papillomavirus) is a sexually transmitted infection but is not a bloodborne pathogen. HIV (Human Immunodeficiency Virus) affects the immune system but is not as virulent as Hepatitis C in terms of bloodborne transmission. HBV (Hepatitis B Virus) is less virulent compared to HCV in the context of bloodborne transmission.

5. The healthcare provider is examining a patient who is reporting "feeling cold."? Which is a mechanism of heat loss in the body?

Correct answer: B

Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss. Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.

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