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. When cleansing the genital area during perineal care, the nurse should _____________.
- A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
- B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
- C. cleanse the rectal area first and then clean the patient's genital area.
- D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.
Correct answer: B
Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.
3. The healthcare provider is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope?
- A. Often used to direct light into the sinuses
- B. Used to examine the structures of the internal ear
- C. Uses a short, broad speculum to help visualize the ear
- D. Directs light into the ear canal and onto the tympanic membrane
Correct answer: D
Rationale: The otoscope is a tool used to examine the ear canal and tympanic membrane, which separates the external and middle ear. It is not intended to direct light into the sinuses or examine the internal structures of the ear. The otoscope typically uses a short, narrow speculum to aid in visualizing the ear canal and tympanic membrane, not a short, broad speculum as mentioned in choice C.
4. When printing out an EKG, a nurse notices that the QRS complexes are extremely small. What should be the next step?
- A. Alert the physician immediately as this is a sign of impending cardiac arrest.
- B. Check to see that all leads are attached and rerun the EKG.
- C. Increase the sensitivity control to 20 mm deflection.
- D. Decrease the run speed to 50.
Correct answer: C
Rationale: Increasing the sensitivity control to 20 mm deflection will double the sensitivity, allowing for better observation of the small QRS complexes. This step is crucial in obtaining a clearer EKG reading. Choice A is incorrect because small QRS complexes do not necessarily indicate impending cardiac arrest; it's more likely a technical issue. Choice B is not the first step to take when small QRS complexes are observed; it's important to adjust the settings first. Choice D is incorrect because decreasing the run speed to 50 is not the appropriate action for this situation; adjusting the sensitivity control is more relevant to improve the visualization of the complexes.
5. During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?
- A. Formulate a nursing diagnosis of impaired gas exchange
- B. Record in the medical record the distance a client ambulates in the hall
- C. Write individualized nursing orders in the care plan
- D. Compare client responses to the desired outcomes for pain relief
Correct answer: B
Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.
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