NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A small fire has erupted in a wastebasket in the client waiting room. Which of the following is the first action of the nurse?
- A. Call 9-1-1
- B. Find the fire extinguisher
- C. Move clients to safety
- D. Throw water on the fire
Correct answer: C
Rationale: When a fire starts in a healthcare setting, the first action of the nurse is to move clients and anyone who may be in danger to a safe location. Ensuring the safety of clients is the top priority during emergencies. While using a fire extinguisher could be a subsequent step to contain the fire, the immediate focus should be on evacuating individuals from harm's way. Calling 9-1-1 is important, but moving clients to safety should be the nurse's initial response. Throwing water on the fire may not be effective or safe, as it can exacerbate some types of fires.
2. What is an attack using microorganisms such as bacteria or viral agents with the intent to harm others called?
- A. Assimilation
- B. Defense intervention
- C. Bioterrorism
- D. Environmental remediation
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.
3. When are manual hematocrits done?
- A. to monitor anemia
- B. by using a microhematocrit tube.
- C. to measure the percentage of plasma to cells.
- D. All of the above.
Correct answer: D
Rationale: Manual hematocrits are performed to monitor anemia, which involves measuring the percentage of red blood cells in the blood. The process involves collecting blood in a microhematocrit tube, then centrifuging it to separate the plasma from the cells. By measuring the ratio of plasma to cells, healthcare providers can assess the patient's hematocrit level. Therefore, all the provided options are correct as they collectively describe the purpose and procedure of manual hematocrits.
4. During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?
- A. Formulate a nursing diagnosis of impaired gas exchange
- B. Record in the medical record the distance a client ambulates in the hall
- C. Write individualized nursing orders in the care plan
- D. Compare client responses to the desired outcomes for pain relief
Correct answer: B
Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.
5. 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.
- A. assault
- B. battery
- C. physical neglect
- D. emotional neglect
Correct answer: B
Rationale: The correct answer is 'battery.' Battery occurs when there is unwanted physical contact or force applied to a person without their consent. In this scenario, force-feeding the patient against their will constitutes battery as the nurse is physically interfering with the patient's body without permission. Assault involves the threat of physical harm, which is not present in the situation described. Physical neglect refers to the failure to provide basic care needs, which is not the case here. Emotional neglect involves the failure to address emotional needs, which is also not applicable in this context.
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