NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Which of the following is the correct sequence for removing personal protective equipment?
- A. Remove gown, gloves, shoe covers, mask
- B. Remove mask, gloves, gown, shoe covers
- C. Remove gloves, gown, mask, shoe covers
- D. Remove shoe covers, mask, gloves, gown
Correct answer: C
Rationale: The correct sequence for removing personal protective equipment is crucial to prevent contamination. When exiting a surgical or aseptic situation, the proper sequence is to first remove gloves, followed by the gown, mask, and finally shoe covers. This order ensures that potentially contaminated items are removed first, minimizing the risk of exposure. Choice A, 'Remove gown, gloves, shoe covers, mask,' is incorrect as gloves should be removed before the gown. Choice B, 'Remove mask, gloves, gown, shoe covers,' is incorrect as gloves should be removed first. Choice D, 'Remove shoe covers, mask, gloves, gown,' is incorrect as gloves should be the first item removed to prevent contamination.
2. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?
- A. Performs the examination from both sides of the bed.
- B. Examines tender or painful areas last to help relieve the patient's anxiety.
- C. Follows a flexible examination sequence, considering the patient's age and condition.
- D. Organizes the assessment to ensure that the patient does not change positions too often.
Correct answer: D
Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.
3. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?
- A. The skin on the arm appears mottled
- B. The cold pack has been in place for 10 minutes
- C. The client complains of feeling nauseated
- D. The capillary refill in the area distal to the arm is 2 seconds
Correct answer: A
Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.
4. Nursing care plans contain which of the following?
- A. nursing diagnoses
- B. medical diagnoses.
- C. MD orders.
- D. intake and output forms
Correct answer: A
Rationale: Nursing care plans are legal documents that contain nursing diagnoses, such as an "Alteration of respiratory function". They also contain patient goals and nursing interventions.
5. The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?
- A. Belief in and worship of God or gods
- B. Being closely tied to one's ethnic background
- C. Attendance at a specific church or place of worship
- D. A connection with something larger than oneself and belief in transcendence
Correct answer: D
Rationale: Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Choice A, 'Belief in and worship of God or gods,' and choice C, 'Attendance at a specific church or place of worship,' are more aligned with religious practices. Choice B, 'Being closely tied to one's ethnic background,' is not a defining aspect of spirituality or religion as it pertains more to cultural identity rather than spiritual beliefs.
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