NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. When educating a client about their new prescription for warfarin, what should the nurse advise?
- A. To have his white blood cell count tested once a month
- B. To avoid any activities that could lead to injury
- C. To avoid eating leafy green vegetables
- D. Both A and B
Correct answer: B
Rationale: The correct answer is to advise the client to avoid any activities that could lead to injury when taking warfarin. Warfarin is an anticoagulant medication that decreases blood clotting, increasing the risk of bleeding. Engaging in activities that may result in injury can lead to uncontrolled bleeding, which can be serious. While monitoring white blood cell count is not specifically related to warfarin therapy, avoiding leafy green vegetables is important due to their vitamin K content, which can interfere with warfarin's effectiveness. Therefore, the client should be educated to avoid activities that could cause injury to prevent potential bleeding complications.
2. The nurse is preparing to examine a 4-year-old child. Which action by the nurse is appropriate for this age group?
- A. Explain the procedures briefly to alleviate the child's anxiety.
- B. Give the child feedback and reassurance during the examination.
- C. Ask the child to undress as needed for the examination.
- D. Perform an examination of the head last.
Correct answer: B
Rationale: For a 4-year-old child, short and simple explanations should be provided to avoid overwhelming the child. It is important to give feedback and reassurance during the examination to create a comforting environment for the child. Asking the child to undress as needed is appropriate for a thorough examination, as children at this age are usually willing to do so. Performing an examination of the head last allows the child to become more comfortable during the assessment. Therefore, the most appropriate action for a 4-year-old child is to provide feedback and reassurance during the examination, ensuring a positive experience for the child.
3. What term is used to describe the sexual response changes among middle-aged men?
- A. Menopause
- B. Climacteric
- C. Generativity
- D. Maturity
Correct answer: B
Rationale: The correct answer is 'Climacteric.' Climacteric specifically refers to the period in middle-aged men characterized by sexual response changes, such as delayed arousal. Menopause, choice A, is incorrect as it is specific to women and marks the cessation of menstrual periods. Generativity, choice C, is unrelated as it refers to the concern for guiding the next generation. Maturity, choice D, is too broad and generally refers to reaching the adult stage of development, not specifically addressing sexual response changes in middle-aged men.
4. What is the BEST blood collection location for a newborn?
- A. the AC
- B. the veins of the forehead
- C. the heel
- D. the fingertips
Correct answer: C
Rationale: When collecting blood from newborns, it is safest and most commonly done by collecting blood from the lateral or medial aspect of the baby's heel. This location is preferred due to the accessibility of the veins and the minimal discomfort caused to the newborn. Veins in the forehead are not commonly used for blood collection in newborns. The fingertips are not optimal for blood collection in newborns due to their small size and the potential for causing discomfort. The AC (antecubital) area, typically used in adults for blood collection, is not recommended for newborns due to the size of their veins and the potential risk of injury.
5. A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This situation illustrates which concept?
- A. Integration
- B. Assimilation
- C. Biculturalism
- D. Heritage consistency
Correct answer: B
Rationale: Assimilation is a unidirectional, linear process moving from unacculturated to acculturated, in which a person develops a new cultural identity and becomes like members of the dominant culture. In this scenario, the woman has adapted to the new culture by learning the language, dressing like her peers, and expressing that her family in Europe would hardly recognize her. This aligns with the process of assimilation. Integration and biculturalism, on the other hand, involve bidirectional and bidimensional processes that induce reciprocal change in both cultures while maintaining aspects of the original culture in one's ethnic identity. Since there is no indication in the question that the woman has retained aspects of her original culture, integration and biculturalism are not the correct concepts. Heritage consistency refers to the degree to which one retains their original or traditional culture, which is not addressed in the scenario provided.
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