NCLEX NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. What is the initial step to take when a patient passes out at the front desk?
- A. Call 911.
- B. Initiate CPR.
- C. Shake the patient and ask if they are okay.
- D. Check for a pulse.
Correct answer: Shake the patient and ask if they are okay.
Rationale: The correct initial step when a patient passes out at the front desk is to shake the patient gently and ask if they are okay. This step aims to assess the patient's level of responsiveness. Checking for a pulse or initiating CPR should only be done if the patient does not respond to being shaken. Calling 911 can be the next step after assessing the patient's immediate condition and providing necessary assistance.
2. When placing a patient in the AP position for an X-ray, what position would the patient be in?
- A. Facing the X-ray film.
- B. Right side against the X-ray film.
- C. Left side against the X-ray film.
- D. Facing away from the X-ray film
Correct answer: D
Rationale: The AP position stands for Anteroposterior Projection. When a patient is in the AP position for an X-ray, they are facing away from the X-ray film. This positioning allows for a clear view of the structures being imaged from front to back. Choices A, B, and C are incorrect because the patient is not facing or positioned against the X-ray film in the AP position, but rather facing away from it to capture the necessary diagnostic information.
3. The client is a 35-year-old multiparous individual scheduled for a tubal ligation. The nurse assesses the client's emotional response to the planned procedure. Which factor in the client’s history will contribute to the healthy resolution of any emotional problem associated with sterilization?
- A. Belief that the surgery will relieve her monthly dysmenorrhea
- B. Knowledge that her partner does not want to have any more children
- C. Feeling that her family is complete and she now has the children she planned for
- D. Recovery from her previous complicated birth and a desire to avoid another birth
Correct answer: Feeling that her family is complete and she now has the children she planned for
Rationale: The correct answer is feeling that her family is complete and she now has the children she planned for. Many couples in their 30s who feel that their families are complete choose sterilization as their method of contraception. Sterilization by means of tubal ligation should not be expected to have an effect on dysmenorrhea. The decision to undergo sterilization should be the individual's own choice and should not be influenced by others, including partners. Decisions regarding sterilization should ideally be made when the individual is not under stress, such as after recovery from a previous complicated birth. Therefore, the key factor contributing to a healthy resolution of emotional issues related to sterilization is the feeling of family completeness and achieving the planned number of children.
4. A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately?
- A. Abdominal distention
- B. A bruit near the epigastric area
- C. 3 episodes of vomiting in the last hour
- D. Blood pressure of 160/90
Correct answer: B: A bruit near the epigastric area
Rationale: A bruit near the epigastric area may indicate the presence of an aortic aneurysm, which is a life-threatening condition requiring immediate medical attention. Abdominal distention, while concerning, may not be as urgent as a potential aneurysm. Vomiting episodes may suggest underlying issues but do not present an immediate life-threatening situation. A blood pressure of 160/90, though elevated, does not pose the same level of immediate threat as a potential aortic aneurysm.
5. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
- A. Inform the client that the blood pressure is high and compare the reading with the client's previously documented blood pressure readings for accuracy.
- B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication.
- C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort during blood pressure measurement.
- D. Compare the current reading with the client's previously documented blood pressure readings.
Correct answer: Compare the current reading with the client's previously documented blood pressure readings.
Rationale: The correct action for the nurse to take first when a client's blood pressure reading is 156/94 mm Hg is to compare the current reading with the client's previously documented readings. This comparison helps determine whether the current reading is abnormal for the client. Option A, which involves informing the client that the blood pressure is high and comparing it with the previous readings, is appropriate as it educates the client and aids in accurate assessment. Option B, contacting the health care provider for medication, is premature without further assessment. Option C, replacing the cuff with a larger one, is incorrect as it may affect the accuracy of the blood pressure measurement and is not a standard practice for managing high blood pressure readings.
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