NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. When should the biohazard emblem be affixed to containers according to the orientation nurse educator reviewing the biohazard legend with a class of new employees?
- A. when there is presence of blood and body fluids.
- B. when there is the need for droplet precautions.
- C. when there is contact isolation.
- D. when there is the potential for airborne transmission.
Correct answer: A
Rationale: The correct answer is 'when there is presence of blood and body fluids.' When handling body substances like blood and body fluids, the risk of transmission of infections increases. Federal regulations mandate warning labels on containers to alert employees and waste collectors. The biohazard emblem consists of a three-ring symbol overlaying a central concentric ring. Blood, wound drainage, feces, and urine are examples of body fluids that can transmit infections and diseases to others. The other choices, B, C, and D, are incorrect because the presence of the biohazard emblem is specifically linked to the handling of blood and body fluids, not to droplet precautions, contact isolation, or airborne transmission.
2. The nurse uses prioritization to determine all of the following except:
- A. time allotment for certain tasks.
- B. appropriate interventions.
- C. treatment procedures.
- D. the need for client education.
Correct answer: C
Rationale: The correct answer is C: "treatment procedures." Prioritization in nursing involves determining the order of importance or urgency of tasks. Treatment procedures are standards of care that need to be followed as defined by the facility or nursing unit. They are not typically subject to prioritization but are mandatory based on established protocols. Time allotment for certain tasks, appropriate interventions, and the need for client education are all aspects that can be influenced by prioritization. For instance, prioritizing tasks helps in managing time effectively, selecting the most suitable interventions, and identifying the necessity for client education as part of the care plan.
3. In a disaster triage situation, which of the following should the nurse be least concerned with regarding a client in crisis?
- A. ability to breathe
- B. pallor or cyanosis of the skin
- C. number of accompanying family members
- D. motor function
Correct answer: C
Rationale: During a disaster triage situation where quick decisions are crucial, the nurse's primary focus should be on factors directly related to the patient's immediate condition and survival. The ability to breathe, pallor or cyanosis of the skin, and motor function are critical indicators of a patient's health status and need for urgent intervention. In contrast, the number of accompanying family members, although important for emotional support, is not a priority when assessing and prioritizing care during a crisis. While emotional support is valuable, the focus in triage is on identifying and addressing the most critical and life-threatening issues first to maximize survival chances. Therefore, the nurse should be least concerned with the number of accompanying family members as it does not directly impact the patient's immediate medical needs in a crisis situation. Choices A, B, and D are all crucial factors to assess a client's health status and determine the urgency of intervention during a disaster triage. The ability to breathe indicates respiratory function, pallor or cyanosis of the skin reflect circulatory and oxygenation status, and motor function can hint at neurological impairment or injury, all of which are vital in determining the severity of the crisis and the immediate medical needs of the patient.
4. To what does legal protection of confidentiality extend?
- A. Written documentation only.
- B. Electronic dissemination of information not identifiable to a specific client.
- C. Only within the court system.
- D. Both written and verbal information.
Correct answer: D
Rationale: Legal protection of confidentiality extends to both written and verbal information that is identifiable as individual private health information. Confidentiality in healthcare settings is vital to protect patients' privacy and trust. Choice A is incorrect because legal protection covers verbal information as well, not just written documentation. Choice B is incorrect as it mentions information not identifiable to a specific client, which wouldn't fall under legal protection of confidentiality. Choice C is incorrect as confidentiality extends beyond just the court system, impacting various healthcare settings and interactions. Therefore, the correct answer is D.
5. Which of the following adverse effects should the client on Floxin be alerted to?
- A. stunting of height in teens and young adults
- B. propensity for anovulatory uterine bleeding
- C. intractable diarrhea
- D. tendon rupture
Correct answer: D
Rationale: The correct answer is tendon rupture. Floxin is a quinolone antibiotic commonly used in respiratory infections and pelvic/reproductive infections. One of the rare adverse effects associated with quinolones is tendon sheath rupture, often affecting the Achilles tendon. Therefore, patients taking Floxin should be alerted to the possibility of tendon rupture. Choices A, B, and C are incorrect as they are not typically associated with Floxin use and are not common adverse effects of quinolone antibiotics. Stunting of height is not a recognized adverse effect of Floxin. Anovulatory uterine bleeding is not a known side effect of quinolones. Intractable diarrhea is not a common adverse effect of Floxin.
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