NCLEX NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. The Rule of Nines is used to:
- A. determine the amount of the body surface that has been burned.
- B. assess the level of oxygen saturation in a body that has been burned.
- C. determine the level of tissue damage that has occurred in a burn.
- D. None of the above.
Correct answer: determine the amount of the body surface that has been burned.
Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.
2. A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure?
- A. A patient admitted for myocardial infarction without cardiac muscle damage.
- B. A postoperative coronary bypass patient, recovering on schedule.
- C. A patient with a history of ventricular tachycardia and syncopal episodes.
- D. A patient with a history of atrial tachycardia and fatigue.
Correct answer: A patient with a history of ventricular tachycardia and syncopal episodes.
Rationale: The correct answer is a patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator is used to deliver an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. These patients are at high risk of life-threatening arrhythmias, which may result in syncope. Patients with atrial tachycardia and fatigue (Choice D) would not typically require an implantable cardioverter-defibrillator as their primary issue is related to atrial arrhythmias. Patients who have had a myocardial infarction without cardiac muscle damage (Choice A) or postoperative coronary bypass patients recovering on schedule (Choice B) are not necessarily at high risk for ventricular arrhythmias and would not be the primary candidates for an implantable cardioverter-defibrillator.
3. After a lengthy explanation of a medical procedure, the patient asks many questions. The physician answers all of the questions to the best of their ability. The patient then gives consent for treatment. The costly equipment and supplies are put into place, and the patient is prepared. Two minutes before the procedure is to start, the patient begins panicking and changes their mind. Which of the following situations would be the best way to avoid litigation?
- A. Document that the patient originally gave consent and proceed if the benefits of the procedure outweigh the patient's wishes.
- B. Have the patient sign a form stating that they are refusing consent. If they refuse to sign, do not proceed with the procedure.
- C. Repeat the explanation of the procedure until the patient understands that having the procedure done is the best form of treatment. Do not proceed with the procedure.
- D. Do not proceed. Document the patient's refusal, have the patient sign a refusal to consent to treatment. If the patient refuses to sign the form, have a witness available to sign.
Correct answer: Do not proceed. Document the patient's refusal, have the patient sign a refusal to consent to treatment. If the patient refuses to sign the form, have a witness available to sign.
Rationale: In this scenario, the best course of action to avoid litigation is to respect the patient's right to refuse treatment, especially when changing their mind before the procedure starts. By not proceeding with the treatment, documenting the patient's refusal, and having the patient sign a refusal to consent form, you are following proper ethical and legal procedures. If the patient refuses to sign the form, having a witness available to sign further strengthens the documentation of the patient's decision. This approach ensures that the patient's autonomy and right to make informed decisions about their healthcare are respected. Choices A, B, and C do not prioritize the patient's right to refuse treatment and could potentially lead to legal issues if treatment is carried out against the patient's wishes.
4. A client with an enlarged prostate is having trouble starting his flow of urine when using the bathroom. Another name for this condition is:
- A. Hesitancy
- B. Oliguria
- C. Retention
- D. Urgency
Correct answer: Hesitancy
Rationale: Urinary hesitancy occurs when a client has difficulty starting a flow of urine while using the bathroom. Hesitancy may be due to physiological factors, such as obstruction from an enlarged prostate, or due to psychological factors, such as anxiety or embarrassment. Oliguria refers to decreased urine output, retention is the inability to empty the bladder fully, and urgency is the sudden and strong need to urinate.
5. A client is diagnosed with ariboflavinosis. Which of the following foods should the nurse serve this client?
- A. Citrus fruits
- B. Milk
- C. Fish
- D. Potatoes
Correct answer: Milk
Rationale: Ariboflavinosis is a vitamin B-2 deficiency. Symptoms may include cracks around the mouth, inflammation of the tongue, or light sensitivity. Foods rich in vitamin B-2, like milk, liver, green vegetables, or whole grains, are recommended. Citrus fruits (choice A) are good sources of vitamin C, not B-2. Fish (choice C) is a source of protein and omega-3 fatty acids but not a significant source of vitamin B-2. Potatoes (choice D) are a source of carbohydrates but do not provide high levels of vitamin B-2.
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