NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A patient is bleeding profusely from an injury near her wrist. Which of the following first aid procedures would be MOST appropriate?
- A. Place a tourniquet on her arm above the injury.
- B. Place pressure on her brachial artery.
- C. Place pressure on her radial nerve.
- D. Cover the bleeding area with wet towels.
Correct answer: B
Rationale: The most appropriate first aid procedure for a patient bleeding profusely from an injury near the wrist is to place pressure on her brachial artery. Applying pressure to the brachial pulse point will help slow down the bleeding. Placing a tourniquet on her arm above the injury is not recommended as it could potentially inhibit blood flow, leading to tissue necrosis. Pressing on the radial nerve or covering the bleeding area with wet towels are not effective in controlling bleeding and may not address the underlying cause.
2. When reviewing the demographics of ethnic groups in the United States, which group does the nurse recall as the largest and fastest-growing population?
- A. Asian
- B. Hispanic
- C. American Indian
- D. African American/Black
Correct answer: B
Rationale: The correct answer is 'Hispanic.' Hispanics are the largest and fastest-growing population in the United States. While African Americans/Blacks, Asians, American Indians, and other groups are significant, Hispanics currently represent the largest demographic group. African American/Black, Asian, and American Indian populations are substantial but not as large or fast-growing as the Hispanic population. Therefore, Hispanic is the most appropriate choice in this scenario.
3. 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?
- A. Restrain the client in bed
- B. Ask a family member to stay with the client
- C. Check the client every 15 minutes
- D. Use a bed exit safety monitoring device
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.
4. The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or healthcare providers, the nurse emphasizes interventions that do which of the following? (Berman & Snyder, 2012, p. 713)
- A. Eliminate the reservoir
- B. Block the portal of exit from the reservoir
- C. Block the portal of entry into the host
- D. Decrease the susceptibility of the host
Correct answer: B
Rationale: To prevent the spread of infection from a chronic carrier, the nurse should focus on blocking the portal of exit from the reservoir, which is the carrier person. By preventing the movement of the organism from the reservoir, the infection can be contained. Eliminating the reservoir is not feasible in this case as the carrier is a chronic carrier. Blocking the portal of entry into the host or decreasing the susceptibility of the host would only impact individual prevention and not the spread from the carrier to others.
5. After a symptom is recognized, the first effort at treatment is often self-treatment. Which of the following statements is true about self-treatment?
- A. "Not recognized as valuable by most health care providers."?
- B. "Usually ineffective and may delay more effective treatment."?
- C. "Always less expensive than biomedical alternatives."?
- D. "Influenced by the accessibility of over-the-counter medicines."?
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.
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