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. The most accurate reading for a temperature is done:

Correct answer: B

Rationale: Aural readings are done through the ear canal. The tympanic membrane shares a blood supply with the hypothalamus, the brain area that regulates body temperature. Taking the temperature aurally through a clean canal ensures an accurate reading. Choice A (Orally) is not the most accurate method for temperature measurement as it can be affected by external factors like drinking hot or cold liquids. Choice C (Rectally) is invasive and less practical for routine temperature monitoring. Choice D (Axially) is not a standard method for temperature measurement and may not provide accurate results.

3. What is the initial step to take when a patient passes out at the front desk?

Correct answer: C

Rationale: The correct initial step when a patient passes out at the front desk is to shake the patient gently and ask if they are okay. This step aims to assess the patient's level of responsiveness. Checking for a pulse or initiating CPR should only be done if the patient does not respond to being shaken. Calling 911 can be the next step after assessing the patient's immediate condition and providing necessary assistance.

4. Which statement best describes evidence-based practice?

Correct answer: D

Rationale: Evidence-based practice involves utilizing the most effective, current, and relevant information to inform nursing care decisions for optimal client outcomes. While research reports and data collection are important components of evidence-based practice, the essence lies in integrating all available information to determine the best course of action. Monitoring compliance with standards, as described in choices A and C, is essential for quality assurance but does not capture the comprehensive nature of evidence-based practice.

5. A 60-year-old patient has been treated for pneumonia for the past 6 weeks. The patient is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. Which is an appropriate rationale for this patient's weight loss?

Correct answer: C

Rationale: Unexplained weight loss in a patient with pneumonia could indicate an underlying short-term illness or a chronic condition like endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Hypertension is not commonly associated with weight loss; it usually leads to weight gain due to fluid retention. Unhealthy eating habits are less likely to explain significant unexplained weight loss over a short period. Mental health dysfunctions can affect appetite but are not typically primary causes of significant unexplained weight loss.

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