NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A nurse caring for a client diagnosed with pertussis is ordered to maintain droplet precautions. Which of the following actions of the nurse upholds droplet precautions?
- A. Assign the client to stay in a negative-pressure room
- B. Use sterilized equipment when sharing between this client and another person with pertussis
- C. Wear a mask if coming within 3 feet of the client
- D. Both A and C
Correct answer: C
Rationale: When caring for a client requiring droplet precautions, it is essential for the nurse to wear a mask when within 3 feet of the client. This practice helps prevent the transmission of droplet particles that may be produced when the client coughs or sneezes. Assigning the client to a negative-pressure room is not typically necessary for droplet precautions unless specifically indicated for airborne precautions. Using sterilized equipment when sharing between clients with pertussis is important for infection control but does not directly relate to droplet precautions. Therefore, the correct action to uphold droplet precautions in this scenario is to wear a mask when coming within close proximity to the client.
2. When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?
- A. The body temperature of the older adult is lower than that of a younger adult.
- B. An older adult's body temperature is approximately the same as that of a young child.
- C. Body temperature varies based on the type of thermometer used.
- D. In older adults, body temperature can fluctuate widely due to less effective heat control mechanisms.
Correct answer: A
Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2�C. Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child. Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used. Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.
3. After taking the vital signs for your patient and finding them to be normal, what should you do next?
- A. Report the vital signs to the doctor
- B. Write the vital signs on a scrap paper
- C. Call the family members
- D. Document them on the graphic VS form
Correct answer: D
Rationale: After assessing and finding that the vital signs are normal for the patient, the appropriate action would be to document them on the graphic VS form. This form is used to track and record vital sign measurements accurately and consistently. Reporting the normal vital signs to the doctor is not necessary unless there are concerning trends or deviations. Writing the vital signs on a scrap piece of paper is not recommended as it may not be an official or reliable record. Calling the family members is unrelated to the process of documenting and tracking vital signs for the patient.
4. A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?
- A. The client lies on his side with the upper leg flexed
- B. The client lies on his back with his head lower than his feet
- C. The client lies on his abdomen with a pillow supporting his head
- D. The client is sitting up at a 90-degree angle
Correct answer: A
Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.
5. Which vacutainer tubes should be used when a requisition calls for blood to be drawn for an H&H and glucose test?
- A. One light blue, one red
- B. Two lavenders
- C. One lavender, one grey
- D. One green, one red
Correct answer: D
Rationale: The correct answer is 'One green, one red.' An H&H test involves hemoglobin and hematocrit, which are components of a complete blood count and are typically drawn in a lavender tube. On the other hand, blood for glucose testing is collected in grey tubes. Therefore, when drawing blood for both an H&H and glucose test, one green tube for glucose and one red tube for H&H should be used. The other choices are incorrect because light blue tubes are used for coagulation studies, lavender tubes are for complete blood counts, and green tubes are for chemistry tests like glucose, while grey tubes are specifically for glucose testing.
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