NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Which of the following is an example of an environmental hazard that may put the healthcare professional at risk of injury?
- A. Loud noise from the hospital maintenance system
- B. Airborne powder containing latex
- C. Chemicals containing ethylene oxide
- D. All of the above
Correct answer: D
Rationale: Healthcare professionals, including nurses, are exposed to various environmental hazards that may negatively impact their physical or mental health. Hazards come in several forms, such as loud noise from hospital systems, which can damage hearing; airborne latex powder, leading to allergic reactions; and chemicals like ethylene oxide, a sterilizing agent that can cause cancer. Therefore, all the options listed pose risks to healthcare professionals, making 'All of the above' the correct answer. Choice A, loud noise, is a hazard that can affect hearing health. Choice B, airborne latex powder, can trigger allergic responses. Choice C, chemicals containing ethylene oxide, are hazardous and can lead to serious health issues. Each option represents a distinct environmental risk that healthcare professionals should be aware of and take precautions against.
2. Following hospitalization for congestive heart failure, a client is discharged. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
- A. High Fowler's
- B. Supine
- C. Left lateral
- D. Low Fowler's
Correct answer: A
Rationale: The correct answer is High Fowler's. Sitting in a chair or resting in a bed in the high Fowler's position helps decrease the cardiac workload and facilitates breathing in clients with congestive heart failure. This position helps reduce venous return and increases lung expansion, improving oxygenation. The supine position (choice B) may lead to increased pressure on the heart and lungs, making it less suitable for these clients. The left lateral position (choice C) is not as effective as High Fowler's in reducing cardiac workload and improving breathing. Low Fowler's position (choice D) does not provide the same benefits as the High Fowler's position for clients with congestive heart failure.
3. While caring for Mrs. Thomas, you see a notation on the nursing care plan that states 'ambulate at least 10 yards qid'. This patient will be assisted with ambulation at which of the following times?
- A. 10:00 AM
- B. 10 am and 2 pm
- C. 10 am and 2 pm
- D. 10 am, 2 pm, 6 pm, and 10 pm
Correct answer: D
Rationale: The correct answer is to assist the patient with ambulation at 10 am, 2 pm, 6 pm, and 10 pm as qid stands for four times per day. This schedule is commonly followed in healthcare facilities to ensure regular ambulation and exercise for the patient. Choices A, B, and C do not cover all the specified times for ambulation as indicated by the qid notation on the care plan.
4. Which of the following activities would the nurse perform during the diagnosing phase of the nursing process? Select all that apply.
- A. Collect and organize client information
- B. Analyze data
- C. Identify problems, risks, and client strengths
- D. Develop nursing diagnoses
Correct answer: B
Rationale: During the diagnosing phase of the nursing process, the nurse analyzes the collected data to identify problems, risks, and client strengths, which then leads to developing nursing diagnoses. Collecting and organizing client information is part of the assessment phase, where data is gathered. Developing nursing diagnoses comes after data analysis in the diagnosing phase. Goal setting is a component of the planning phase, which follows the diagnosing phase.
5. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse would take when performing a physical examination?
- A. Washing one's hands after removing gloves is necessary, even if the gloves are still intact
- B. Hands are washed before and after every physical patient encounter
- C. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another
- D. Gloves are worn throughout the entire examination to demonstrate concern regarding the spread of infectious diseases
Correct answer: B
Rationale: The most appropriate action for the nurse to take when performing a physical examination is to wash their hands before and after every physical patient encounter. This practice helps prevent the spread of infection. Hands should also be washed after contact with blood, body fluids, secretions, and excretions, and after contact with any equipment contaminated with body fluids. It is crucial to wash hands after removing gloves, even if the gloves appear intact. Choice A is incorrect because washing hands after removing gloves is necessary to ensure thorough hygiene. Choice C is incorrect because hands should be washed before and after every patient encounter, not just before examining each body system. Choice D is incorrect because gloves should be worn when there is potential contact with body fluids, but they do not need to be worn throughout the entire examination.
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