patients that are exhibiting signs of cyanosis will
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Nursing Elites

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. Patients exhibiting signs of cyanosis will:

Correct answer: C

Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from low blood oxygen levels. When a patient exhibits cyanosis, it indicates that their blood is poorly oxygenated, leading to a higher concentration of CO2 compared to oxygen. Options A and B are incorrect as cyanosis is associated with low oxygen levels, not hyperoxia or increased O2 saturation. Therefore, the correct answer is that patients exhibiting cyanosis will have blood levels of CO2 higher than O2 levels.

2. When a nurse's hand comes in contact with a client's blood after providing wound care, what is the next action the nurse should take?

Correct answer: B

Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.

3. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?

Correct answer: D

Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.

4. Which of the following is a negative outcome associated with impaired mobility?

Correct answer: B

Rationale: A client with impaired mobility may develop changes in body systems that put them at risk of further illness or injury. One negative outcome associated with impaired mobility is orthostatic hypotension, where blood pressure drops significantly when moving from a sitting or lying position to a standing position. This drop in blood pressure can lead to symptoms such as dizziness or fainting. This occurs because blood circulates more slowly or pools in the distal extremities due to impaired mobility. Choice A is incorrect because increased calcium absorption is not a typical negative outcome associated with impaired mobility. Choice C is incorrect because a decrease in mucus in the bronchi and lungs is not a common negative outcome of impaired mobility. Choice D is incorrect because thickening of vessel walls in the circulatory system is not directly associated with impaired mobility.

5. The nurse is discussing the term subculture with a student nurse. Which statement by the nurse would best describe subculture?

Correct answer: D

Rationale: A subculture refers to a group of people within a larger culture who share distinct beliefs, values, or attitudes that are not universal among all members of the larger culture. Subcultures can emerge based on factors such as ethnicity, religion, education, occupation, age, and gender. The correct answer describes the concept of a subculture accurately. Choices A, B, and C are incorrect because they do not capture the essence of a subculture. Fitting people into the majority culture, identifying small groups who distance themselves from the larger culture, or singling out individuals facing differential treatment do not define subculture. Subcultures represent specific groups with shared characteristics that differentiate them from the broader cultural norms.

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