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. Mr. and Mrs. K have just adopted a newborn infant and are preparing to take him home from the hospital for the first time. Which safety measure is most appropriate for the clients in this situation?
- A. Turn the handles of pans on the stove inward
- B. Set up a baby gate at the top of the stairs
- C. Cover electrical outlets with child-proof plugs
- D. Install an approved car seat that is facing backward in the back seat
Correct answer: D
Rationale: Parents of newborn infants should use an approved car seat that has been installed facing backward in the back seat of the car. Securing infants in car seats, even from the first ride home from the hospital, promotes safety while transporting. While safety measures at home such as baby gates or outlet covers are important, they are not the priority safety measures until the baby is old enough to be mobile. The car seat is crucial for protecting the newborn during transportation, ensuring proper positioning and restraint in the event of sudden stops or accidents. Turning handles of pans on the stove inward, setting up a baby gate, and covering electrical outlets are important safety measures at home but are not as critical for the immediate safety of a newborn during transportation.
3. The acronym FAST is used to help responders remember the steps to recognizing which of the following conditions?
- A. Onset of labor in a pregnant woman
- B. Stroke
- C. Heart attack
- D. Migraine
Correct answer: B
Rationale: The correct answer is B: Stroke. The acronym FAST is used to help recognize the signs of a stroke. The letters stand for Face, Arms, Speech, and Time. This mnemonic helps in identifying facial drooping, arm weakness, speech difficulties, and the importance of time in seeking emergency care. Choices A, C, and D are incorrect because the FAST acronym specifically pertains to stroke recognition, not the onset of labor, heart attacks, or migraines.
4. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed?
- A. Avoid palpating reportedly “tender” areas as this may cause pain.
- B. Palpate tender areas quickly to minimize patient discomfort.
- C. Initiate the assessment with deep palpation while encouraging the patient to relax and take deep breaths.
- D. Begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch.
Correct answer: D
Rationale: The correct approach is to begin the assessment with light palpation to detect surface characteristics and to acclimate the patient to touch. This allows the nurse to first assess surface features before proceeding to deeper palpation. Starting with light palpation also helps the patient become more comfortable with being touched, creating a smoother examination experience. Palpating tender areas quickly, as suggested in choice B, can increase patient discomfort. Deep palpation, as in choice C, is typically performed after light palpation to avoid discomfort and ensure proper assessment. Avoiding palpation of tender areas first, as in choice A, helps prevent causing unnecessary pain and should be done towards the end of the assessment.
5. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?
- A. The skin on the arm appears mottled
- B. The cold pack has been in place for 10 minutes
- C. The client complains of feeling nauseated
- D. The capillary refill in the area distal to the arm is 2 seconds
Correct answer: A
Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.
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