NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. One of your patients is dependent on a mechanical ventilator for their respiratory needs. The patient cannot breathe on their own. Suddenly, the lights in the patient's room and the entire nursing unit go off. You realize that the electric power has been lost. What is the first thing that you should do for this patient?
- A. Plug the ventilator into the red outlet in the room.
- B. Plug the ventilator into the blue outlet in the room.
- C. Use an Ambu bag to ventilate the patient.
- D. Call the doctor about this emergency.
Correct answer: B
Rationale: In healthcare facilities, emergency generators are in place in case of power outages. The red outlets in patient rooms are connected to the emergency generator and provide power during such situations. By plugging the ventilator into the red outlet, you ensure that the patient's mechanical ventilation needs are met despite the power loss. Using an Ambu bag or calling the doctor should be secondary actions after ensuring the ventilator is powered correctly. Plugging the ventilator into the blue outlet is incorrect and can result in the ventilator not functioning during a power outage.
2. During a class on the aspects of culture, the instructor shares that culture has four basic characteristics. Which statement correctly reflects one of the characteristics of culture?
- A. Static and unchanging
- B. Members sharing similar physical characteristics
- C. Members sharing a common geographic origin and religion
- D. Adapted to specific conditions related to environmental and technical factors
Correct answer: D
Rationale: Culture has four basic characteristics, one of which is that it is adapted to specific conditions related to environmental and technical factors and to the availability of natural resources. The other three characteristics are: (1) learned from birth through the processes of language acquisition and socialization; (2) shared by all members of the cultural group; and (3) dynamic and ever-changing. Culture is not static and unchanging but is dynamic and ever-changing. Members of a culture do not necessarily share similar physical characteristics; that refers to race. Similarly, members of a culture do not necessarily share a common geographic origin and religion; that refers to ethnicity.
3. Which of the following signs or symptoms indicates a possible nutritional deficiency?
- A. Subcutaneous fat at the waist and abdomen
- B. Presence of papillae on the surface of the tongue
- C. Straight arms and legs
- D. Pale conjunctiva
Correct answer: D
Rationale: A client with poor nutritional intake may have pale mucous membranes surrounding the eye, or the conjunctiva. This area should normally be pink, indicating good circulation and a lack of irritation or dryness. Improper nutrition can manifest as numerous signs in the body, including bowed legs, pale mucous membranes, a smooth or beefy tongue, and poor muscle tone. Subcutaneous fat at the waist and abdomen is not a sign of nutritional deficiency but rather of excess fat deposition. The presence of papillae on the surface of the tongue is normal and not indicative of a nutritional deficiency. Straight arms and legs are also typical anatomical features and not specifically related to nutritional deficiencies.
4. 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.
5. When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
- A. Securely grasp the client's arm and leg.
- B. Put bed rails up on the side of bed opposite from the nurse.
- C. Correctly position and use a turn sheet.
- D. Lower the head of the client's bed slowly
Correct answer: B
Rationale: When turning an immobile bedridden client without assistance, the best action to ensure client safety is to put bed rails up on the side of the bed opposite from the nurse. This is important because the nurse can only stand on one side of the bed, so having bed rails on the opposite side prevents the client from falling out of bed. Option A, which suggests securely grasping the client's arm and leg, can potentially cause client injury to the skin or joints. Options C and D, correctly positioning and using a turn sheet, and lowering the head of the client's bed slowly, respectively, are useful techniques during client turning but are of lower priority in terms of safety compared to the use of bed rails.
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