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. Which of the following is the correct sequence for removing personal protective equipment?
- A. Remove gown, gloves, shoe covers, mask
- B. Remove mask, gloves, gown, shoe covers
- C. Remove gloves, gown, mask, shoe covers
- D. Remove shoe covers, mask, gloves, gown
Correct answer: C
Rationale: The correct sequence for removing personal protective equipment is crucial to prevent contamination. When exiting a surgical or aseptic situation, the proper sequence is to first remove gloves, followed by the gown, mask, and finally shoe covers. This order ensures that potentially contaminated items are removed first, minimizing the risk of exposure. Choice A, 'Remove gown, gloves, shoe covers, mask,' is incorrect as gloves should be removed before the gown. Choice B, 'Remove mask, gloves, gown, shoe covers,' is incorrect as gloves should be removed first. Choice D, 'Remove shoe covers, mask, gloves, gown,' is incorrect as gloves should be the first item removed to prevent contamination.
3. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?
- A. "At least two (2) full meals a day are eaten."?
- B. "We go to a group discussion every week at our community center."?
- C. "We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?
- D. "The medication is not a problem to have taken three (3) times a day."?
Correct answer: C
Rationale: The correct answer is, '"We have safety bars installed in the bathroom and have 24-hour alarms on the doors."?' Ensuring the safety of a client with Alzheimer's disease is crucial in home care. Installing safety features like bars in the bathroom and alarms on doors help prevent accidents and injuries. This contributes to creating a safe environment that promotes independence and autonomy for the client. Choices A, B, and D are incorrect because while they are important aspects of care, ensuring safety in the home environment takes precedence in caring for a client with Alzheimer's disease.
4. When planning a cultural assessment, what component should the nurse include?
- A. Family history
- B. Chief complaint
- C. Medical history
- D. Health practices
Correct answer: D
Rationale: When conducting a cultural assessment, it is essential to include the patient's health practices. Health practices encompass the beliefs, values, and behaviors related to health and illness within a specific cultural context. These practices provide insight into how individuals perceive and manage their health. Family history, chief complaint, and medical history are crucial components of a patient's overall assessment but do not directly relate to a cultural assessment. Focusing on health practices allows the nurse to better understand the patient's cultural background and tailor care to meet their specific needs.
5. When dismissing a 5-year-old boy from the pediatrics unit, what type of seat belt restraint should the child wear as the parents drive the car to the front door of the hospital?
- A. A 5-point restraint in the back seat, facing backward
- B. A booster seat with a lap and shoulder belt in the back seat
- C. A lap belt in the back seat
- D. A lap and shoulder belt in the front seat
Correct answer: B
Rationale: A 5-year-old child riding in a car should use a restraint system for safety. The Centers for Disease Control and Prevention recommend that children under 13 years should not ride in the front seat of a car due to safety concerns. For a 5-year-old child, a booster seat with a lap and shoulder belt in the back seat is the most appropriate choice. This setup ensures proper protection and restraint for the child's size and age. Choice A is incorrect because a 5-point restraint system facing backward is not suitable for a 5-year-old child in a car. Choice C is incorrect as a lap belt alone does not provide adequate protection for a child of this age. Choice D is incorrect as children should not be seated in the front seat, especially at this young age.
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