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
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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 playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?

Correct answer: A

Rationale: For 7-year-old children, play serves an important role in developing cooperation, logical reasoning, and social skills. Organizing sports and games with rules is beneficial as it helps children understand the importance of rules, promotes teamwork, and fosters social interactions. Finger paints and water play, while fun, may not target the specific developmental needs of this age group. Similarly, 'Dress-up' clothes and props can encourage imaginative play but may not necessarily promote cooperation and logical reasoning. Chess and television programs are more suited for older children and may not engage 7-year-olds as effectively in developing the desired skills.

3. What is an attack using microorganisms such as bacteria or viral agents with the intent to harm others called?

Correct answer: C

Rationale: Bioterrorism is the act of using harmful agents like bacteria or viruses with the intention to harm others. In the context of healthcare, nurses may be involved in disaster response if bioterrorism weapons affect the community. Choice A, assimilation, refers to the process of absorbing and integrating information or ideas. Choice B, defense intervention, does not specifically relate to the intentional use of microorganisms to harm others. Choice D, environmental remediation, involves the process of cleaning up pollution or contamination in the environment, which is unrelated to the deliberate use of pathogens for harmful purposes.

4. 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?

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.

5. The instructor is teaching a class on basic assessment skills. Which of the following statements is true regarding the stethoscope and its use?

Correct answer: B

Rationale: The stethoscope does not magnify sound but effectively blocks out extraneous room noises. The correct orientation of the earpieces is with the slope pointing forward toward the examiner's nose, not posteriorly. The tubing length of a stethoscope should ideally be between 14 to 18 inches (36 to 46 cm) to avoid sound distortion. Using tubing longer than this range can distort sound. Both the fit and quality of the stethoscope are crucial for accurate auscultation and assessment, highlighting their significance in clinical practice. Therefore, the correct answer is that the stethoscope blocks out extraneous room noise but does not magnify sound.

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