NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Which of the following actions is most appropriate for reducing the risk of infection during the post-operative period?
- A. Flush the central line with heparin at least every four hours
- B. Administer narcotic analgesics as needed
- C. Remove the urinary catheter as soon as the client is ambulatory
- D. Order a high-protein diet for the client
Correct answer: C
Rationale: The most appropriate action to reduce the risk of infection during the post-operative period is to remove the urinary catheter as soon as the client is ambulatory. Urinary catheters can serve as a source of bacteria, increasing the risk of infection in the bladder or urethra. By removing the catheter promptly once the client is mobile, the risk of infection can be minimized. Option A, flushing the central line with heparin, is not directly related to reducing urinary tract infections. Option B, administering narcotic analgesics as needed, is important for pain management but does not directly address infection prevention. Option D, ordering a high-protein diet, may be beneficial for wound healing but does not specifically target infection risk reduction in the post-operative period.
2. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?
- A. Collaborating with the client to establish healthcare goals
- B. Reviewing the client's medical record history
- C. Explaining the purpose of administered medications to the client
- D. Rapidly resetting priorities for client care based on changes in the client's condition
Correct answer: D
Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.
3. Which of the following is a disadvantage of using a dry heat application?
- A. Dry heat is more likely to cause burns than moist heat
- B. Dry heat does not penetrate deeply into the tissues
- C. Dry heat causes the skin to dry out more quickly
- D. Dry heat can quickly cause skin breakdown
Correct answer: C
Rationale: The correct answer is that dry heat causes the skin to dry out more quickly. When comparing dry and moist heat applications, dry heat is less likely to cause burns and skin breakdown. However, one of the disadvantages of dry heat is that it does not penetrate deeply into the tissues and may lead to faster drying out of the skin. This can have negative effects on skin integrity and overall comfort during therapy. Choice A is incorrect because dry heat is less likely to cause burns than moist heat. Choice B is incorrect as dry heat may not penetrate deeply into tissues. Choice D is incorrect as dry heat is less likely to cause skin breakdown compared to moist heat.
4. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?
- A. Get the nurse who is caring for the patient.
- B. Tell the nurse that the patient has had another seizure.
- C. Observe the patient for any injuries and call out for help.
- D. Nothing. This patient is not one of your assignments.
Correct answer: C
Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.
5. Which of the following situations indicates the need to file an incident report?
- A. The neon sign directing parking for visitors has burned out
- B. A nurse must send a syringe pump to maintenance for annual service
- C. A client's blood pressure dropped to 90/55 after receiving a dose of morphine
- D. A client's spouse becomes angry and is asked to leave the premises
Correct answer: D
Rationale: An incident report is necessary for documenting unexpected events that occur in a healthcare setting. Situations that warrant filing an incident report include client accidents, medication errors, security problems, or disruptive behaviors that involve clients, families, or visitors. In this scenario, when a client's spouse displays disruptive behavior and is asked to leave the premises, it is essential to document this incident to ensure a record of the event and its resolution. Choices A, B, and C do not involve disruptive behavior or safety concerns that would require an incident report to be filed.
Similar Questions
Access More Features
NCLEX RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access
NCLEX RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access