NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A healthcare provider attempts to plug in a sequential compression device when they notice a tingling sensation in their hands while touching the cord. What is the next action of the healthcare provider?
- A. Attempt to plug the device into a different outlet
- B. Inspect the cord for damage; if none is present, continue to use the device
- C. Discontinue the device and send it to the maintenance department for inspection
- D. Notify the supervisor that the unit is at risk of an electrical fire
Correct answer: C
Rationale: Feeling a tingling sensation when touching an electrical cord is a warning sign that the device may be malfunctioning. This sensation indicates a potential electrical current leak, which could pose a risk of harm. The correct action is to immediately discontinue the use of the device and send it to the maintenance department for inspection. Continuing to use the device without addressing the issue could lead to electric shock or fire hazards. Trying to plug the device into a different outlet does not address the underlying problem of potential device malfunction. Notifying the supervisor about the risk of an electrical fire is important, but the immediate action should be to stop using the device and have it inspected by maintenance professionals. Therefore, the best course of action is to discontinue the device and ensure it is checked thoroughly before further use.
2. For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?
- A. Assessing the patient for jaundice
- B. Providing oral hygiene after a meal
- C. Palpating the abdomen for distention
- D. Assisting the patient to choose the diet
Correct answer: B
Rationale: Providing oral hygiene after a meal is an appropriate task to delegate to unlicensed assistive personnel (UAP) as it falls within their scope of practice. UAP can assist with basic personal care activities like oral hygiene. Assessing the patient for jaundice and palpating the abdomen for distention involve making clinical assessments that require a higher level of education and training, typically performed by licensed practical/vocational nurses (LPNs/LVNs) or registered nurses (RNs). Assisting the patient to choose the diet also requires specialized knowledge and would be more appropriate for a nurse to address, considering the complexity of dietary requirements in cirrhosis.
3. A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?
- A. Refer the infant to a physician for further evaluation.
- B. Consider these findings normal for a 1-month-old infant.
- C. Expect the chest circumference to be greater than the head circumference.
- D. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
Correct answer: B
Rationale: In infants, a normal head measurement is approximately 32 to 38 cm, and it is usually around 2 cm larger than the chest circumference. These measurements vary with age; between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference becomes greater than the head circumference. Given that the 1-month-old infant's head measurement is within the typical range and slightly larger than the chest circumference, the nurse should consider these findings normal. There is no indication to refer the infant for further evaluation or to have the parent return for re-evaluation in 2 weeks, as these measurements fall within the expected parameters for a 1-month-old infant.
4. Should standard precautions be used when providing post mortem care to a patient who has died from a massive heart attack and had no other diseases, illnesses, or infections?
- A. Yes, because the patient must be treated with respect
- B. Yes, you still must use standard precautions
- C. No, because the patient had no infections
- D. No, because this is not respectful
Correct answer: B
Rationale: Yes, you must still use standard precautions when providing post mortem care, regardless of the patient's medical history. Standard precautions are essential to prevent the transmission of potential infectious agents and protect both the healthcare provider and others from exposure. Even if the patient did not have known infections, it is crucial to maintain a safe environment and uphold professional standards of care. Choice A is incorrect as using standard precautions is primarily for infection control rather than solely for respect. Choices C and D are incorrect as the absence of infections or the notion of respect does not negate the need for standard precautions in post mortem care.
5. When checking for proper blood pressure cuff size, which guideline is correct?
- A. The standard cuff size is appropriate for all sizes.
- B. The length of the rubber bladder should equal 80% of the arm circumference.
- C. The width of the rubber bladder should equal 80% of the arm circumference.
- D. The width of the rubber bladder should equal 40% of the arm circumference.
Correct answer: D
Rationale: When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect. Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.
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