NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. When performing CPR, at what rate should chest compressions be applied?
- A. 100 per minute
- B. 60 per minute
- C. As quickly as possible
- D. 200 per minute
Correct answer: A
Rationale: During CPR, chest compressions should be applied at a rate of 100 compressions per minute in order to effectively circulate blood and oxygen to vital organs. Option A, '100 per minute,' is the correct answer as it aligns with the recommended compression rate in CPR guidelines. Option B, '60 per minute,' is incorrect as it is too slow and may not provide adequate circulation. Option C, 'As quickly as possible,' is vague and does not specify the recommended compression rate. Option D, '200 per minute,' is incorrect as it exceeds the recommended rate and may not be as effective in maintaining perfusion.
2. Which of the following statements best describes footdrop?
- A. The foot is permanently fixed in the dorsiflexion position
- B. The foot is permanently fixed in the plantar flexion position
- C. The toes of the foot are permanently fanned
- D. The heel of the foot is permanently rotated outward
Correct answer: B
Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.
3. 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: B
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.
4. What is the proper personal protective equipment necessary for collecting a sputum specimen?
- A. Gloves and face mask
- B. Level Three Biocontainment uniforms
- C. Eye protection and shoe covers
- D. Splash shield and face mask
Correct answer: A
Rationale: When collecting a sputum specimen, it is crucial to protect against potential airborne droplets that may spread disease. The best personal protective equipment for this task includes gloves and a face mask. Gloves help prevent the spread of contaminants through hand contact, while a face mask protects the respiratory tract from inhaling infectious agents. Choice B, Level Three Biocontainment uniforms, is excessive and unnecessary for routine sputum specimen collection. Choice C, eye protection and shoe covers, does not address the specific risks associated with sputum collection. Choice D, splash shield and face mask, provides additional protection that is not typically required for sputum specimen collection, making it less appropriate than gloves and a face mask.
5. Which desired outcome written by the nurse is correctly written and measurable?
- A. Client will have a normal bowel pattern by April 2
- B. The client will lose 4 lbs. within the next 2 weeks
- C. The nurse will provide skin care at least 3 times each day
- D. The client will breathe better after resting for 10 minutes
Correct answer: B
Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Option B is correctly written and measurable as it includes all the required elements: subject (client), action verb (lose), conditions (within the next 2 weeks), and the level at which the behavior should occur (4 lbs.). Option A lacks the conditions and a specific level, making it not measurable. Option C is a nursing intervention rather than a client goal. Option D does not provide a specific level at which the client should perform the desired behavior, making it not measurable as well.
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