NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A client is being assisted with ambulation in the hallway using a gait belt when they become dizzy and start to faint. What is the first action the nurse should take?
- A. Stand behind the client and prepare to catch them if they fall
- B. Assist the client to sit in the nearest chair or slide down along a wall
- C. Grasp the client under the arms and pull them upward
- D. Call for help from nearby staff
Correct answer: A
Rationale: If a client becomes dizzy and starts to faint while being assisted with ambulation, the nurse's first action should be to assist the client into a sitting position to prevent or reduce the impact of a fall. This can be done by guiding the client to sit in the nearest chair or sliding down along a wall for support. Option A is incorrect because standing behind the client may not prevent a fall and could potentially lead to injury. Option C is incorrect as pulling the client upward may worsen the situation. Option D, calling for help, is not the first action to take when the client is at risk of falling.
2. Intermittent fevers are:
- A. fevers which come and go.
- B. fevers which rise and fall but are always considered above the patient's average temperature.
- C. fevers which fluctuate more than three degrees and never return to normal.
- D. None of the above.
Correct answer: A
Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.
3. A healthcare professional is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?
- A. Cephalic
- B. Median cubital
- C. Basilic
- D. All of the above
Correct answer: D
Rationale: The correct answer is 'All of the above.' All three of these veins - the cephalic, median cubital, and basilic veins - are located in the antecubital space, which is the area in front of the elbow on the arm. The cephalic vein runs along the outer side of the arm, the basilic vein runs along the inner side of the arm, and the median cubital vein is a connecting vein between the cephalic and basilic veins. Therefore, all three veins can be accessed when drawing blood from the antecubital space. Choices A, B, and C are incorrect because each of these veins individually can be found in the antecubital space.
4. A patient's urine specimen tested positive for bilirubin. Which of the following is most true?
- A. The patient should be evaluated for kidney disease
- B. The specimen was probably left at room temperature for more than two hours
- C. The specimen is positive for bacteria
- D. The specimen should be stored in an area protected from light
Correct answer: D
Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing. Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease. Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels. Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.
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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