NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. 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.
2. Which of the following may represent an upper airway obstruction?
- A. Retractions
- B. Elongated expiratory phase
- C. Stridor
- D. Expiratory wheezing
Correct answer: C
Rationale: Stridor is the sound produced by turbulent airflow through a partially obstructed upper airway. It is a classic sign of upper airway obstruction. While an elongated expiratory phase may indicate lower airway obstruction, stridor specifically points to an upper airway issue. Retractions are also often seen in upper airway obstruction due to the increased effort of breathing. Expiratory wheezing, on the other hand, is more indicative of lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD).
3. What is the flap of tissue that covers the trachea upon swallowing called?
- A. Epidermis
- B. Endocardium
- C. Epiglottis
- D. Epistaxis
Correct answer: C
Rationale: The correct answer is C: Epiglottis. The epiglottis is a flap of tissue that covers the trachea when swallowing to prevent food or liquid from entering the airway. Choice A, Epidermis, is the outer layer of the skin and is not related to the trachea. Choice B, Endocardium, is the inner lining of the heart chambers and is also unrelated to the trachea. Choice D, Epistaxis, refers to a nosebleed and is not the correct term for the tissue covering the trachea.
4. Which of the following is an example of physical abuse?
- A. A slap to the person's hand
- B. Threatening the person
- C. Ignoring and isolating a person
- D. Leaving a patient soiled for hours
Correct answer: A
Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.
5. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client?
- A. Loosen pressure dressings on wounds
- B. Use assistance to lift a client in bed
- C. Check temperature of water used in a sponge bath
- D. Position the client in a prone position
Correct answer: C
Rationale: To reduce environmental stimuli that may cause discomfort for a client, nurses can implement various interventions. Checking the temperature of the water used in a sponge bath is crucial to prevent burns from water that is too hot or discomfort from water that is too cold. This intervention addresses a common source of discomfort for clients during personal care. Loosening pressure dressings on wounds, although important for wound care, does not directly address environmental stimuli. Using assistance to lift a client in bed is about proper positioning and preventing injury rather than reducing environmental stimuli. Positioning the client prone is not a suitable intervention for reducing discomfort caused by environmental stimuli.
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