NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Patients exhibiting signs of cyanosis will:
- A. show signs of hyperoxia.
- B. have increased O2 saturation.
- C. have blood levels of CO2 higher than O2 levels.
- D. None of the above.
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. Which practice will help reduce the risk of a needlestick injury?
- A. Expose the end of the needle only when ready to enter the room for the procedure
- B. Never recap a needle after use
- C. Keep a sharps container nearby where it can be easily accessed
- D. Exchange needles from a central area rather than passing them between workers
Correct answer: C
Rationale: To reduce the risk of a needlestick injury, it is essential to keep a sharps container nearby where it can be easily accessed. This practice ensures quick and safe disposal of needles after use, minimizing the chances of accidental needlesticks. Recapping needles should be avoided as it increases the risk of injuries. Passing needles between workers should also be avoided to prevent accidental needle pricks during handovers. Therefore, the best practice to prevent needlestick injuries is to maintain a sharps container nearby for safe and immediate disposal of needles.
3. The most accurate reading for a temperature is done:
- A. Orally
- B. Aurally through a clean canal
- C. Rectally
- D. Axially
Correct answer: B
Rationale: Aural readings are done through the ear canal. The tympanic membrane shares a blood supply with the hypothalamus, the brain area that regulates body temperature. Taking the temperature aurally through a clean canal ensures an accurate reading. Choice A (Orally) is not the most accurate method for temperature measurement as it can be affected by external factors like drinking hot or cold liquids. Choice C (Rectally) is invasive and less practical for routine temperature monitoring. Choice D (Axially) is not a standard method for temperature measurement and may not provide accurate results.
4. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
- A. Document the seizure
- B. Perform neurologic checks
- C. Take the patient's vital signs
- D. Restrain the patient for protection
Correct answer: C
Rationale: After a patient with migraine headaches has a seizure, it is important to assess their vital signs to monitor their condition. This task can be safely delegated to a nursing assistant as it falls within their scope of practice. Documenting the seizure and performing neurologic checks require a higher level of training and should be done by a nurse or healthcare provider. Restraint should never be used as a first-line intervention after a seizure unless there is an immediate threat to the patient's safety, and it should be done following proper protocols and with appropriate training.
5. A resident brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. What rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug?
- A. Controls stray electrical currents.
- B. Promotes efficient use of electricity.
- C. Shuts off the appliance if there is an electrical surge.
- D. Divides the electricity among the appliances in the room.
Correct answer: A
Rationale: A three-pronged plug functions as a ground to dissipate stray electrical currents. This helps prevent electrical shocks and ensures the safety of the user. Choice B is incorrect because the number of prongs on a plug does not impact the efficient use of electricity. Choice C is incorrect because a three-pronged plug does not shut off the appliance during an electrical surge; that role is typically fulfilled by surge protectors. Choice D is incorrect as a three-pronged plug does not divide electricity among appliances in a room; it primarily serves as a safety measure to handle excess electrical currents.
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