NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. According to the American Heart Association standards, high-quality CPR for an adult includes all of the following EXCEPT:
- A. Push hard
- B. Push fast
- C. Allow chest recoil between compressions
- D. Pause CPR as each drug is administered
Correct answer: D
Rationale: High-quality CPR for adults should not be paused for drug administration. The correct CPR technique involves pushing hard and fast, at a rate of at least 100 compressions per minute and to a depth of at least 2 inches. It is also essential to allow chest recoil between compressions to enable proper blood circulation. Pausing CPR for drug administration would delay the delivery of continuous chest compressions, which are crucial for maintaining blood flow and oxygenation during cardiac arrest.
2. What technique would the nurse use to accurately assess a rectal temperature in an adult?
- A. Use a lubricated blunt tip thermometer.
- B. Insert the thermometer 2 to 3 inches into the rectum.
- C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
- D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
Correct answer: A
Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.
3. 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.
4. When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?
- A. When the infant is sleeping
- B. At the end of the examination
- C. Before auscultation of the thorax
- D. At about the middle of the examination
Correct answer: B
Rationale: The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.
5. What term is used to refer to generalized wasting of body tissues and malnutrition?
- A. Entropion
- B. Confabulation
- C. Induration
- D. Cachexia
Correct answer: D
Rationale: Cachexia is the correct term used to describe the generalized wasting of body tissues, ill health, and malnutrition associated with some chronic diseases. It involves a loss of fat tissue to protect the bones and joints. Clients with cachexia are at risk of pressure ulcers and other complications due to malnutrition and poor health. Entropion refers to an eyelid condition, confabulation is a memory disturbance, and induration is the abnormal hardening of a part of the body.
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