NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Which of the following safety precautions should the nurse discuss when working with an immunocompromised client?
- A. Avoid canned foods and increase consumption of fresh fruits and vegetables
- B. Hand-wash utensils after use and allow them to air dry
- C. Only drink tap water that has been filtered or boiled before consumption
- D. Never eat meals prepared in restaurants
Correct answer: C
Rationale: The correct answer is to only drink tap water that has been filtered or boiled before consumption. Immunocompromised clients are susceptible to infections, so it is essential to take precautions to prevent exposure to harmful pathogens. Drinking tap water that has been filtered or boiled helps eliminate potential pathogens that could be harmful to the client's health. Choices A, B, and D do not directly address the issue of avoiding potential pathogens that could compromise the health of an immunocompromised client. Thus, they are incorrect. Hand-washing utensils, avoiding canned foods, and increasing fruit and vegetable consumption are good general hygiene practices but may not specifically address the needs of an immunocompromised client.
2. For a healthcare worker under normal conditions with unsoiled hands, effective hand hygiene between patients requires which of the following?
- A. At least a 15-second scrub with plain soap and water
- B. At least a 23-minute scrub with an antimicrobial soap
- C. Use of an alcohol-based antiseptic hand-rub
- D. Wearing a mask when scrubbing
Correct answer: C
Rationale: Effective hand hygiene between patients for a healthcare worker with unsoiled hands involves using an alcohol-based antiseptic hand rub. This method is sufficient for cleaning hands that are not visibly soiled. The use of an antimicrobial soap or a prolonged scrubbing time is unnecessary and not recommended in this scenario. Wearing a mask is not required for routine hand hygiene and does not contribute to effective hand cleaning.
3. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?
- A. 240 cc
- B. 120 cc
- C. 8 cc
- D. 0 cc because Italian ice is not a fluid
Correct answer: A
Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.
4. You are taking care of 5 patients today. One of your patients wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care problem must you deal with first?
- A. The water
- B. Help to the bathroom
- C. The chest pain
- D. The crying person
Correct answer: C
Rationale: The chest pain must be addressed immediately as it could indicate a serious condition like a heart attack. Treating chest pain is a top priority in healthcare settings due to the potential life-threatening nature of the symptom. Providing immediate attention to chest pain ensures prompt assessment, diagnosis, and intervention, which are crucial for patient safety and well-being. Addressing the other needs, such as providing water, assisting with bathroom needs, or emotional support, can follow once the urgent issue of chest pain has been managed. While the other patient concerns are important, the critical nature of chest pain requires immediate action to rule out severe cardiac events and provide appropriate care.
5. You are taking care of 7 patients today. One of your residents wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care task is the lowest in terms of priority?
- A. The water
- B. Help to the bathroom
- C. The chest pain
- D. The crying person
Correct answer: D
Rationale: The lowest priority patient care task in this scenario is addressing the emotional need of the patient who is crying because his daughter did not visit him today. While emotional support is important, the other needs - providing water, assisting to the bathroom, and addressing chest pain - are physical needs that must take priority as they directly impact the patient's well-being and health. It is crucial to acknowledge and address emotional needs but in this situation, the physical needs of the patients should be addressed first.
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