a nurse is preparing to assist a client from his bed into a wheelchair which action is essential to maintain client safety in this situation
Logo

Nursing Elites

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. A client is being transferred from a bed to a wheelchair. Which action is essential to maintain client safety in this situation?

Correct answer: D

Rationale: When transferring a client from a bed to a wheelchair, it is crucial to prioritize client safety. Locking both wheels on the wheelchair before moving the client is essential as it adds stability and prevents the wheelchair from moving unexpectedly during the transfer process. Placing the wheelchair at the foot of the bed allows for easier transfer, but ensuring the wheels are locked is more critical for safety. Maintaining a 12-inch space between the wheelchair and the bed is not as essential as ensuring wheel locks are engaged. While placing the footplates in the lowest position can enhance client comfort, it is not a safety measure that is as critical as securing the wheelchair by locking its wheels before the transfer.

2. Which of the following situations indicates the need to file an incident report?

Correct answer: D

Rationale: An incident report is necessary for documenting unexpected events that occur in a healthcare setting. Situations that warrant filing an incident report include client accidents, medication errors, security problems, or disruptive behaviors that involve clients, families, or visitors. In this scenario, when a client's spouse displays disruptive behavior and is asked to leave the premises, it is essential to document this incident to ensure a record of the event and its resolution. Choices A, B, and C do not involve disruptive behavior or safety concerns that would require an incident report to be filed.

3. Which of the following statements best describes substance P?

Correct answer: D

Rationale: Substance P is a neurotransmitter found in the brain and the dorsal horn of the spinal column, not just in the brain. It is associated with pain transmission and modulation. Substance P is known to cause inflammation, edema, and pain. While it plays a role in pain perception, it does not decrease a client's sensitivity to pain (Choice A), nor are its levels typically drawn before administering narcotic analgesics (Choice B). Although substance P is involved in pain control, it is not responsible for managing depression (Choice C). Therefore, the correct statement is that substance P is found in the dorsal horn of the spinal column.

4. According to the American Heart Association standards, high-quality CPR for an adult includes all of the following EXCEPT:

Correct answer: D

Rationale: High-quality CPR for adults should not be paused for drug administration. The correct CPR technique involves pushing hard and fast, at a rate of at least 100 compressions per minute and to a depth of at least 2 inches. It is also essential to allow chest recoil between compressions to enable proper blood circulation. Pausing CPR for drug administration would delay the delivery of continuous chest compressions, which are crucial for maintaining blood flow and oxygenation during cardiac arrest.

5. What is the minimum amount of personal protective equipment for a nurse when working with a newborn immediately after a high-risk delivery in a client's room?

Correct answer: C

Rationale: The correct answer is gloves. When attending a high-risk delivery and handling a newborn immediately after birth, the minimum personal protective equipment required for a nurse includes gloves. This is essential to protect the nurse from potential exposure to the mother's blood or body fluids that may be present on the newborn's skin. Choices A, B, and D include additional protective equipment that is not necessary for this specific scenario. Wearing gloves is crucial for infection control and to prevent the transmission of pathogens.

Similar Questions

In which situation would the nurse use bimanual palpation technique?
What is the MOST ACCURATE statement regarding the ESR test?
How many cc are there in 25 ounces?
A patient has a goal of eating at least 50% of each meal. The patient refuses to eat, so a nurse force-feeds the patient in order for them to reach their goal of eating at least 50% of the meal. The nurse has committed __________ against this patient.
Which principle of body mechanics may help to reduce the risk of a back injury?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses