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. A nursing care plan states, 'Assist the patient to the bedside commode PRN.' When will this patient get this assistance to the commode?
- A. Whenever needed
- B. At bedtime
- C. During the night
- D. During the day
Correct answer: A
Rationale: The correct answer is 'Whenever needed.' The abbreviation 'PRN' stands for 'pro re nata,' which translates to 'as needed' or 'whenever necessary.' This means that the patient will receive assistance to the commode whenever they require it, based on their individual needs and condition. Choices B, C, and D are incorrect because 'PRN' does not specify a specific time like bedtime, during the night, or during the day; instead, it indicates assistance based on the patient's needs.
3. The healthcare professional is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?
- A. Turgor
- B. Texture
- C. Density
- D. Consistency
Correct answer: C
Rationale: Percussion is a technique used to assess the density of underlying organs by producing sounds that help determine their location and size. Turgor, texture, and consistency are primarily assessed through palpation, not percussion. Turgor refers to skin elasticity, texture pertains to the feel of the tissue surface, and consistency relates to the firmness or resistance of the tissue.
4. 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.
5. When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment?
- A. Goggles
- B. Gown
- C. Surgical mask
- D. Clean gloves
Correct answer: A
Rationale: Goggles may be reused unless they are overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off. Gowns are at high risk for contamination and should be used only once and then discarded or washed. Surgical masks and gloves should never be washed or reused. Goggles provide eye protection from splashes and should be cleaned and disinfected after each use to ensure proper protection.
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