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 an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck. Which action by the nurse is appropriate?
- A. Ask the patient about the item and its significance.
- B. Ask the patient to lock the item with other valuables in the hospital's safe.
- C. Tell the patient that a family member should take valuables home.
- D. No action is necessary.
Correct answer: A
Rationale: The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from 'evil spirits.' When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet's meaning to the patient. Asking the patient to lock the item with other valuables in the hospital's safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient's cultural health practices.
3. Which of the following actions is most appropriate for reducing the risk of infection during the post-operative period?
- A. Flush the central line with heparin at least every four hours
- B. Administer narcotic analgesics as needed
- C. Remove the urinary catheter as soon as the client is ambulatory
- D. Order a high-protein diet for the client
Correct answer: C
Rationale: The most appropriate action to reduce the risk of infection during the post-operative period is to remove the urinary catheter as soon as the client is ambulatory. Urinary catheters can serve as a source of bacteria, increasing the risk of infection in the bladder or urethra. By removing the catheter promptly once the client is mobile, the risk of infection can be minimized. Option A, flushing the central line with heparin, is not directly related to reducing urinary tract infections. Option B, administering narcotic analgesics as needed, is important for pain management but does not directly address infection prevention. Option D, ordering a high-protein diet, may be beneficial for wound healing but does not specifically target infection risk reduction in the post-operative period.
4. The healthcare professional is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
- A. Measuring the infant's length using a tape measure
- B. Weighing the infant on an electronic standing scale
- C. Measuring the chest circumference at the nipple line with a tape measure
- D. Measuring the head circumference by wrapping the tape measure around the head
Correct answer: C
Rationale: For accurate measurements, specific techniques are required for different parameters in infants. Measuring the chest circumference involves encircling the chest at the nipple line. Length should be measured on a horizontal measuring board. Weight should be measured using a platform-type balance scale. Head circumference measurement entails ensuring the tape is aligned at the eyebrows and prominent frontal and occipital bones for the widest span. Therefore, the correct technique for measuring the chest circumference is at the nipple line with a tape measure. The other options are incorrect because length should be measured on a horizontal board, weight should be measured on a balance scale, and head circumference should be measured around the head, not over the nose and cheekbones.
5. Which of the following is a fat-soluble vitamin?
- A. Vitamin C
- B. Vitamin D
- C. Vitamin B-6
- D. Riboflavin
Correct answer: B
Rationale: The correct answer is Vitamin D. Fat-soluble vitamins are those that can be stored in the body, allowing excess amounts to be stored for later use. While this storage ability can help prevent deficiencies, it also poses a risk of toxicity. The fat-soluble vitamins are A, E, D, and K. Choice A, Vitamin C, is water-soluble, not fat-soluble. Choice C, Vitamin B-6, and Choice D, Riboflavin, are also water-soluble vitamins and not fat-soluble.
Similar Questions
Access More Features
NCLEX RN Basic
$1/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access
NCLEX RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access