NCLEX NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. 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.
2. A 20-year-old female client with noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?
- A. Accept and document the client's wish to refrain from bathing.
- B. Offer to give the client a bed bath, avoiding the perineal area.
- C. Obtain written brochures about menstruation to give to the client.
- D. Teach the importance of personal hygiene during menstruation to the client.
Correct answer: Teach the importance of personal hygiene during menstruation to the client.
Rationale: The correct answer is to teach the importance of personal hygiene during menstruation to the client. While respecting the client's beliefs, it is essential to provide education on maintaining hygiene during menstruation. This empowers the client with knowledge to make informed decisions. Options A and B can be considered after providing education. Option C, obtaining brochures, is not the priority as direct communication and teaching would be more effective in addressing the client's concerns.
3. Using the illustrated technique, the healthcare provider is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?
- A. Hyperresonance
- B. Tripod positioning
- C. Accessory muscle use
- D. Reduced chest expansion
Correct answer: Reduced chest expansion
Rationale: The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest expansion would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion, not palpation. Accessory muscle use and tripod positioning would be assessed by inspection, not palpation.
4. Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?
- A. Confront the delusional material directly by telling Gio that this simply is not so.
- B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
- C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
- D. Isolate Gio when he begins to talk about these beliefs.
Correct answer: Tell Gio that this must seem frightening to him but that you believe he is safe here.
Rationale: The most therapeutic response in this situation is to acknowledge Gio's feelings of fear and validate his experience by expressing empathy ('this must seem frightening to him'). By reassuring Gio that he is safe in the current environment, the nurse can help reduce his anxiety and build trust. Choice A is not recommended as directly confronting delusional beliefs may lead to increased distress and resistance. Choice C delays addressing Gio's concerns and may not provide immediate support. Choice D of isolating Gio can worsen his feelings of paranoia and distrust in the treatment setting.
5. Which of the following diseases is caused by the Bordetella pertussis bacterium?
- A. German Measles
- B. RSV
- C. Meningitis
- D. Whooping Cough
Correct answer: Whooping Cough
Rationale: Bordetella pertussis is the bacterium responsible for causing Whooping Cough, also known as pertussis. Meningitis can be caused by various bacteria, but not specifically by Bordetella pertussis. German Measles, also known as Rubella, and RSV (Respiratory Syncytial Virus) are viral infections and are not caused by the Bordetella pertussis bacterium. Therefore, the correct answer is Whooping Cough, caused by Bordetella pertussis.
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