NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A patient's Foley catheter has been discontinued. You will dispose of this patient equipment by doing which of the following?
- A. Wearing gloves and then placing this equipment in the regular trash can after it is placed in a paper bag.
- B. Simply placing this equipment in the regular trash can after it is placed in a paper bag.
- C. Wearing gloves and then placing this equipment into a special 'hazardous waste' container.
- D. Simply placing this equipment in the 'hazardous waste' container after it is placed in a paper bag.
Correct answer: C
Rationale: When disposing of used patient equipment, such as a Foley catheter, that has come in contact with bodily fluids, it is considered hazardous waste. The correct procedure involves wearing gloves and placing the Foley bag and tubing into a special 'hazardous waste' container. This container is marked as 'Hazardous' and is typically red to indicate the potential danger of its contents. Placing the equipment in a regular trash can, even if placed in a paper bag, is not appropriate as it does not meet the standards for disposing of hazardous waste. Therefore, options A and B are incorrect. Similarly, simply placing the equipment in a 'hazardous waste' container after it is placed in a paper bag is also incorrect as direct disposal into the designated container while wearing gloves is the proper protocol, making option D incorrect.
2. Which of the following descriptors is most appropriate to use when stating the 'problem' part of a nursing diagnosis?
- A. Grimacing
- B. Anxiety
- C. Oxygenation saturation 93%
- D. Output 500 mL in 8 hours
Correct answer: B
Rationale: The problem part of a nursing diagnosis in the context of nursing care plans should focus on the client's response to a life process, event, or stressor. This response is what is used to identify the nursing diagnosis. 'Anxiety' is the most appropriate descriptor for the problem part of a nursing diagnosis as it reflects a psychological response that can be addressed by nursing interventions. 'Grimacing' is a physical manifestation and not the problem itself. 'Oxygenation saturation 93%' and 'Output 500 mL in 8 hours' are data points or cues that a nurse would use to formulate the nursing diagnostic statement, not the actual problem being addressed.
3. Which of these guidelines would a healthcare professional follow when measuring a patient's weight?
- A. The patient is always weighed wearing only undergarments.
- B. The type of scale matters and should be consistent day to day.
- C. The patient should remove heavy outer clothing, shoes, and jackets before weighing.
- D. Attempts should be made to weigh the patient at approximately the same time of day if a sequence of weights is necessary.
Correct answer: D
Rationale: When measuring a patient's weight, it is important to ensure accuracy and consistency. If a sequence of repeated weights is necessary, the healthcare professional should attempt to weigh the patient at the same time of day and with the same types of clothing worn each time. It is crucial to use a standardized balance or electronic standing scale for accurate weight measurement. Choice A is incorrect as patients should remove heavy outer clothing, shoes, and jackets before being weighed for accurate results. Choice B is incorrect because the type of scale used does matter and should be consistent for reliable weight tracking. Choice C is incorrect as patients should not leave on heavy outer clothing, shoes, or jackets as these items can add to the weight recorded inaccurately.
4. Nursing care plans are _______________?
- A. written by CNAs before they provide care
- B. guidelines of care that all nursing team members use
- C. used by nurses but not by nursing assistants
- D. used by nursing assistants but not by nurses
Correct answer: B
Rationale: Nursing care plans are comprehensive documents created by registered nurses to outline individualized care for patients. These plans serve as guidelines for all members of the nursing team, including nursing assistants, to ensure consistent and quality care. Choice A is incorrect as CNAs typically assist in implementing the care plan rather than creating it. Choice C is incorrect as nursing care plans are utilized by all members of the nursing team, not exclusive to only nurses. Choice D is incorrect as nursing assistants also utilize nursing care plans to provide patient care effectively.
5. After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods?
- A. Return demonstration
- B. Explanation
- C. Achievement of 90 on written test
- D. Have the client explain the procedure to the family
Correct answer: A
Rationale: After teaching the client on crutch walking technique, assessing the client's understanding is crucial. The most effective method to evaluate the client's comprehension of a hands-on skill like crutch walking technique is through a return demonstration. This allows the nurse to observe the client performing the technique, ensuring they have grasped the instructions correctly and can execute the skill safely. While providing an explanation can help clarify doubts, it may not confirm the client's ability to perform the skill. Achieving a high score on a written test assesses cognitive understanding but not necessarily the practical application of the skill. Having the client explain the procedure to the family does not directly assess their ability to perform the skill themselves; it tests their ability to communicate the information to others.
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