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. The client reports nausea and constipation. Which of the following would be the priority nursing action?
- A. Collect a stool sample
- B. Complete an abdominal assessment
- C. Administer an anti-nausea medication
- D. Notify the physician
Correct answer: B
Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (Choice A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (Choice C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (Choice D) should come after the assessment to provide a complete picture of the client's condition.
3. An older adult patient brought to the emergency department by a family member is wandering outside, saying, "I can't find my way home."? The patient is confused and unable to answer questions. What is the nurse's best action?
- A. Document the patient's mental status and obtain other assessment data from the family member.
- B. Record the patient's answers to questions on the nursing assessment form.
- C. Ask an advanced practice nurse to perform the assessment interview.
- D. Call for a mental health advocate to maintain the patient's rights.
Correct answer: A
Rationale: In this scenario, the patient is confused and unable to answer questions. When the patient is unable to provide information, it is important to use secondary sources such as family members. The nurse's best action is to document the patient's mental status and obtain additional assessment data from the family member. This approach will help gather relevant information about the patient's condition. Asking an advanced practice nurse to perform the assessment interview is not necessary as it is within the staff nurse's scope of practice. Calling for a mental health advocate is also unnecessary at this point as the priority is to assess the patient's condition and gather information from the family member.
4. The abbreviation pc is defined as ________________.
- A. before the meal
- B. with the meal
- C. after the meal
- D. post corpi
Correct answer: C
Rationale: The correct answer is C: 'after the meal.' In medical terminology, 'pc' is an abbreviation for 'post cibum,' which means 'after eating' or 'after the meal.' This term is used to indicate when a medication should be taken concerning meals. Choices A, B, and D are incorrect. 'Before the meal' (A) is typically abbreviated as 'ac,' 'with the meal' (B) is abbreviated as 'pc,' and 'post corpi' (D) is not a valid medical abbreviation or term.
5. Specific gravity in urinalysis:
- A. compares the concentration of urine to that of distilled water
- B. is useless when the patient is dehydrated
- C. can only be measured using a refractometer
- D. None of the above
Correct answer: A
Rationale: Specific gravity in urinalysis measures the concentration of solutes in urine compared to that of distilled water. This comparison helps in assessing the kidney's ability to concentrate urine properly. It is a valuable test even in dehydrated patients as it provides insights into renal function. Specific gravity can be measured using various methods, including a refractometer or reagent strips. Normal specific gravity readings of human urine typically range from 1.005 to 1.030. Choice A is correct as it accurately describes the purpose of specific gravity in urinalysis. Choices B and C are incorrect as specific gravity remains relevant in dehydrated patients and can be measured using different techniques, not solely a refractometer.
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