NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Which of the following may represent an upper airway obstruction?
- A. Retractions
- B. Elongated expiratory phase
- C. Stridor
- D. Expiratory wheezing
Correct answer: C
Rationale: Stridor is the sound produced by turbulent airflow through a partially obstructed upper airway. It is a classic sign of upper airway obstruction. While an elongated expiratory phase may indicate lower airway obstruction, stridor specifically points to an upper airway issue. Retractions are also often seen in upper airway obstruction due to the increased effort of breathing. Expiratory wheezing, on the other hand, is more indicative of lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD).
2. Who is the center of care?
- A. The doctor
- B. The administrator
- C. The patient
- D. The nurse
Correct answer: C
Rationale: The PATIENT is the center of care and the core of the healthcare team. The PATIENT holds the utmost importance within the healthcare setting. Healthcare professionals collaborate as a team to effectively address the needs of the patient. The primary focus should always be on the patient, who plays a crucial role in decision-making. While other healthcare team members, such as doctors, nurses, and administrators, play vital roles, the patient remains the central figure. The patient has the fundamental right to receive quality care from all members of the healthcare team.
3. A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process?
- A. Use sterile solution at room temperature
- B. Position the client in a comfortable position
- C. Clamp the catheter at the level above the injection port
- D. Inject sterile solution through the injection port into the catheter
Correct answer: D
Rationale: When performing closed intermittent system catheter irrigation, the nurse should use sterile solution at room temperature with sterile technique. It is important to position the client comfortably for easy access to the catheter site and to assess the abdomen during the procedure. Clamping the catheter should be done below the level of the injection port, not above. The correct step is to inject sterile solution through the injection port into the catheter, allowing the fluid to travel up the catheter to irrigate the tubing and the bladder.
4. A patient has been told to monitor her LH levels. Which of the following potential conditions might the patient be suffering from?
- A. Menorrhagia
- B. Grave's Disease
- C. Menopause
- D. Infertility
Correct answer: D
Rationale: Luteinizing hormone (LH) is released by the pituitary gland to stimulate ovulation. One of the common reasons for monitoring LH levels is infertility. In women with infertility, LH levels are monitored to time intercourse accurately to maximize the chances of conception. Menorrhagia (choice A) is characterized by heavy menstrual bleeding and is not directly related to LH levels. Grave's Disease (choice B) is an autoimmune disorder affecting the thyroid gland and is not typically monitored by LH levels. Menopause (choice C) is a natural process marking the end of a woman's reproductive years and is not a condition where LH monitoring for infertility is common.
5. During an examination, a nurse notices a draining ulceration on a patient's lower leg. What is the most appropriate action in this situation?
- A. Wash hands and then contact the physician.
- B. Continue to examine the ulceration and then wash hands.
- C. Wash hands, put on gloves, and continue with the examination of the ulceration.
- D. Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last.
Correct answer: C
Rationale: In this scenario, the most appropriate action is to wash hands, put on gloves, and then continue examining the ulceration. Wearing gloves is crucial when there is a possibility of contact with body fluids, as in the case of a draining ulceration. Contacting the physician is not necessary at this point; the immediate focus should be on proper infection control by washing hands and wearing gloves. Changing the order of the examination is not recommended as it is important to follow a systematic approach to avoid missing any crucial assessments.
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