NCLEX 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: Shave the client's chest to remove the hair
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. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?
- A. Bile-stained fecal emesis
- B. The passage of currant jelly-like stools
- C. Failure to pass meconium stool in the first 24 hours after birth
- D. Sausage-shaped mass palpated in the upper right abdominal quadrant
Correct answer: Failure to pass meconium stool in the first 24 hours after birth
Rationale: Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. Failure to pass meconium stool within the first 24 hours after birth is a key clinical manifestation associated with this disorder. This finding should prompt further assessment to confirm the suspected diagnosis. Other assessment findings in imperforate anus may include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options A, B, and D describe findings typically noted in intussusception, a different condition characterized by bowel obstruction and telescoping of the intestines that can present with bile-stained fecal emesis, the passage of currant jelly-like stools, and a sausage-shaped mass palpated in the upper right abdominal quadrant.
3. During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important?
- A. Understanding what will be discussed
- B. Knowing that the nurse is trying to be helpful
- C. Knowing what to expect from the relationship
- D. Preparing for termination of the relationship
Correct answer: Knowing what to expect from the relationship
Rationale: During the initial stages of a therapeutic relationship, having a clear understanding of participants' roles is crucial as it helps in defining the structure and boundaries of the relationship. This clarity assists in setting expectations and establishing a framework for interaction, allowing the client to focus on the therapeutic process rather than on uncertainties regarding their role or the nurse's role. Option A, understanding what will be discussed, is important but not directly related to defining roles. Option B, knowing that the nurse is trying to be helpful, is about the intent of the nurse rather than the roles of the participants. Option D, preparing for termination of the relationship, is premature in the beginning phase and not directly related to understanding roles.
4. What drives respiration in a patient with advanced chronic respiratory failure?
- A. Hypoxemia
- B. Hypocapnia
- C. Hypercapnia
- D. None of the above
Correct answer: Hypoxemia
Rationale: In patients with advanced chronic respiratory failure, such as those with chronic obstructive pulmonary disease (COPD), the respiratory drive shifts from being primarily stimulated by high levels of carbon dioxide (hypercapnia) to being driven by low oxygen levels (hypoxemia). This shift is due to the body's adaptation to chronic respiratory acidosis and hypoxemia. As a result, hypoxemia becomes the primary stimulus for respiration in these patients. Hypocapnia, a low level of carbon dioxide, is not a common driver of respiration in patients with advanced chronic respiratory failure. Therefore, the correct answer is hypoxemia.
5. Which of the following is a true statement about palliative care?
- A. The goal of palliative care is to provide end-of-life care for a client as they transition toward death.
- B. Palliative care provides comfort and support for those who may have a terminal illness.
- C. Palliative care provides resources for funeral arrangements after death.
- D. Palliative care is a support network for family and friends after the death of a loved one.
Correct answer: Palliative care provides comfort and support for those who may have a terminal illness.
Rationale: Palliative care is a type of care that focuses on providing support and comfort to individuals who may have a terminal illness or severe symptoms. It aims to improve the quality of life for both the individual receiving care and their family. While it can be provided in various settings, including hospitals, homes, or specialized facilities, the primary focus is on symptom management and addressing the physical, emotional, and spiritual needs of the individual. Choice A is incorrect because palliative care is not solely limited to end-of-life care but also includes managing symptoms and improving quality of life. Choice C is incorrect as palliative care is focused on providing care and support during the individual's life, not on funeral arrangements after death. Choice D is incorrect as palliative care is primarily directed towards the individual receiving care, although it may also provide support to their family and friends during the care process.
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