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. Your patient who had AIDS/HIV has just died. Should you still use standard precautions as you provide post-mortem care?
- A. Yes, because the virus is still transmissible
- B. Yes, because respect must still be maintained
- C. No, because the virus is no longer transmissible
- D. No, because it is disrespectful
Correct answer: A
Rationale: Yes, you should still use standard precautions even after an HIV/AIDS patient has died. The virus can remain infectious after death, and healthcare workers need to protect themselves from potential exposure. Choice B is incorrect because while respect is important, the primary reason for using standard precautions is to prevent transmission of infectious diseases. Choice C is incorrect as the virus can still be transmissible even after the patient's death. Choice D is incorrect as using standard precautions is a matter of infection control, not a question of respect.
3. What does the medical term 'diaphoresis' mean?
- A. Profuse vomiting
- B. Profuse sweating
- C. Gasping for air
- D. None of the above
Correct answer: B
Rationale: The correct answer is B: Profuse sweating. Diaphoresis is a medical term that refers to excessive sweating. It is commonly seen in emergency situations such as heart attacks or diabetic episodes. Choice A, 'Profuse vomiting,' is incorrect as diaphoresis is not related to vomiting. Choice C, 'Gasping for air,' is also incorrect as it refers to difficulty breathing, not sweating. Choice D, 'None of the above,' is incorrect as diaphoresis specifically relates to sweating.
4. A patient in a clinic has been diagnosed with hepatitis A. What is the most likely route of transmission?
- A. Sexual contact with an infected partner
- B. Contaminated food
- C. Blood transfusion
- D. Illegal drug use
Correct answer: B
Rationale: The correct answer is contaminated food. Hepatitis A is primarily transmitted through the fecal-oral route, often through the ingestion of contaminated food or water. It is caused by the Hepatitis A virus (HAV), which is a single-stranded, positive-sense RNA virus. Sexual contact with an infected partner is more commonly associated with hepatitis B and C. Blood transfusion is a potential route for hepatitis B and C transmission due to bloodborne pathogens. Illegal drug use, particularly involving shared needles, is a common route for hepatitis C transmission.
5. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?
- A. A person of small stature is at increased risk for injury from entrapment.
- B. A history of a previous fall from a bed with raised side rails is significant.
- C. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails.
- D. Creative use of alternative measures indicates respect for the patient's dignity.
Correct answer: A
Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.
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