NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A nurse is preparing to change a client's dressing for a burn wound on his foot. Which of the following interventions is appropriate for this process?
- A. Wash the wound with cleanser, rinse, and pat dry
- B. Bind the wound tightly, secure with tape, and elevate the foot
- C. Contact the physician after the dressing change is complete
- D. Provide analgesics for the client after the procedure
Correct answer: A
Rationale: When changing the dressing for a burn wound, it is essential to follow appropriate interventions to prevent infection, reduce pain, and support healing. In this scenario, after removing the old dressing, it is crucial to wash the wound gently with a suitable cleanser, rinse the area thoroughly, and then pat it dry. This process helps in maintaining cleanliness, reducing the risk of infection, and providing a conducive environment for healing. Binding the wound tightly (Choice B) can impede circulation and delay healing. Contacting the physician after the dressing change (Choice C) may be necessary in specific situations but is not a standard step in routine dressing changes. Providing analgesics after the procedure (Choice D) is important for pain management but is not directly related to the dressing change itself.
2. Patients have a right to ______________.
- A. only enough information so they can comply with care
- B. ALL of their health-related information
- C. small amounts of information so they do not get nervous
- D. moderate amounts of information unless they are old
Correct answer: B
Rationale: Patients have a legal right to access all of their health-related information. This includes details about their health condition, treatment options, test results, and any other relevant data. Providing patients with all their health-related information empowers them to make informed decisions about their care, promotes transparency in the healthcare process, and respects their autonomy. Choices A, C, and D are incorrect because they restrict the information patients should receive based on assumptions or limitations, which goes against the principle of patient autonomy and their right to access their complete health-related information.
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. In the Gram Stain procedure, which component acts as the mordant?
- A. Crystal violet
- B. Methyl alcohol
- C. Iodine
- D. Safranin
Correct answer: C
Rationale: In the Gram Stain procedure, the mordant is Gram's Iodine. The purpose of the mordant is to form a complex with the crystal violet, enhancing its ability to bind to the cell wall. Crystal violet is actually the primary stain used in the Gram Stain procedure to initially color all cells. Methyl alcohol is the decolorizer that removes the crystal violet from certain cell types. Safranin is the counterstain used to stain those cells that did not retain the crystal violet stain after the decolorization step.
5. While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?
- A. They are able to make simple associations of ideas
- B. They are able to think logically in organizing facts
- C. Interpretation of events originates from their own perspective
- D. Conclusions are based on previous experiences
Correct answer: B
Rationale: At the age of 10, children are in the concrete operations stage according to Piaget. They are capable of mature thought when allowed to manipulate and organize objects. This means they can think logically, organize facts, and understand cause-and-effect relationships. Choices A, C, and D are incorrect. While simple associations of ideas may occur, the key cognitive ability at this stage is the capacity for logical thought and organization of information. Interpretation of events from their own perspective is more characteristic of younger children, and conclusions based on previous experiences are more aligned with older children or adults.
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