a nurse is caring for a clients wound that has started to bleed after providing wound care the nurse removes her gloves and notes that a small amount
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Nursing Elites

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. When a nurse's hand comes in contact with a client's blood after providing wound care, what is the next action the nurse should take?

Correct answer: B

Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.

2. A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed but is unable to ambulate without help. What is the most appropriate safety measure?

Correct answer: D

Rationale: Option D is the most appropriate safety measure in this scenario. Using a bed exit safety monitoring device allows the client to retain some independence while ensuring that the nursing staff is alerted when assistance is needed. This solution promotes client safety without compromising their autonomy. Option A, restraining the client in bed, can lead to increased agitation, confusion, and a loss of independence. Option B, asking a family member to stay with the client, shifts the responsibility away from the healthcare team. Option C, checking the client every 15 minutes, is not a sufficient safety measure as the client could attempt to get out of bed in the unobserved interval, risking falls and injury.

3. After a symptom is recognized, the first effort at treatment is often self-treatment. Which of the following statements is true about self-treatment?

Correct answer: D

Rationale: After a symptom is identified, the first effort at treatment is often self-treatment. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the internet and mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. Health care providers are recognizing the value of a wide variety of alternative, complementary, and traditional interventions. Many self-treatments, such as over-the-counter medications, are effective. Self-treatment is not always less expensive. Choice A is incorrect as health care providers are recognizing the value of self-treatment. Choice B is incorrect because self-treatment can be effective in many cases. Choice C is incorrect as self-treatment is not always less expensive; it depends on the specific treatment being used.

4. A healthcare professional is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?

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.

5. Patients exhibiting signs of cyanosis will:

Correct answer: C

Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from low blood oxygen levels. When a patient exhibits cyanosis, it indicates that their blood is poorly oxygenated, leading to a higher concentration of CO2 compared to oxygen. Options A and B are incorrect as cyanosis is associated with low oxygen levels, not hyperoxia or increased O2 saturation. Therefore, the correct answer is that patients exhibiting cyanosis will have blood levels of CO2 higher than O2 levels.

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A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?

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