NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A healthcare professional is preparing to administer a dose of platelets to a client. Which of the following actions must the healthcare professional perform before giving the platelets?
- A. Start an IV of 0.9% Normal Saline to administer with the platelets
- B. Ensure the container with the platelets is intact and not damaged
- C. Verify the client's identity using two unique identifiers
- D. Check the client's chart to ensure no contraindications to platelet transfusion
Correct answer: B
Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.
2. Why should direct care providers avoid glued-on artificial nails?
- A. Interfere with dexterity of the fingers.
- B. Could fall off in a patient's bed.
- C. Harbor microorganisms.
- D. Can scratch a patient.
Correct answer: C
Rationale: Direct care providers, including nurses, should avoid glued-on artificial nails because studies have shown that artificial nails, especially when cracked, broken, or split, create crevices where microorganisms can thrive and multiply. This can lead to an increased risk of transmitting infections to patients. Therefore, the primary reason for avoiding glued-on artificial nails is their potential to harbor harmful microorganisms, making option C the correct choice. Options A, B, and D are incorrect because while they may present some issues, the primary concern is the risk of microbial contamination associated with artificial nails.
3. The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.
- A. Client has an actual health problem
- B. Client has a wellness diagnosis
- C. Collaborative health problem needs to be written
- D. Possible nursing diagnosis exists
Correct answer: B
Rationale: The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.
4. Which of the following is NOT an acceptable abbreviation?
- A. D/C
- B. tid
- C. bid
- D. qid
Correct answer: A
Rationale: The correct answer is A: D/C. D/C is not an acceptable abbreviation as it can be easily confused with both 'discharge' and 'discontinue.' The abbreviations 'tid' (three times a day), 'bid' (twice a day), and 'qid' (four times a day) are commonly used in medical contexts to indicate dosing frequencies and are widely accepted in healthcare settings.
5. Efforts by healthcare facilities to reduce the incidence of hospital-acquired infections (HAIs) include an awareness of which of the following?
- A. The CDC requires all states to report HAI rates from each hospital.
- B. Ensure that the restraints are tied to the side rails.
- C. The gastrointestinal tract is a common site for HAIs.
- D. Joint Commission considers death or serious injury from HAIs a sentinel event.
Correct answer: D
Rationale: Efforts to reduce hospital-acquired infections (HAIs) involve being aware that the Joint Commission considers death or serious injury resulting from HAIs a sentinel event, which must be reported. While more than 20 states require reporting of HAI rates to the CDC, it is not a nationwide CDC requirement. The gastrointestinal tract is not a specific common site for HAIs; rather, bacteria are the primary cause. Ensuring restraints are properly secured is important for patient safety but not directly related to reducing HAIs.
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