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: C
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. A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?
- A. Refer the infant to a physician for further evaluation.
- B. Consider these findings normal for a 1-month-old infant.
- C. Expect the chest circumference to be greater than the head circumference.
- D. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
Correct answer: B
Rationale: In infants, a normal head measurement is approximately 32 to 38 cm, and it is usually around 2 cm larger than the chest circumference. These measurements vary with age; between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference becomes greater than the head circumference. Given that the 1-month-old infant's head measurement is within the typical range and slightly larger than the chest circumference, the nurse should consider these findings normal. There is no indication to refer the infant for further evaluation or to have the parent return for re-evaluation in 2 weeks, as these measurements fall within the expected parameters for a 1-month-old infant.
3. When dismissing a 5-year-old boy from the pediatrics unit, what type of seat belt restraint should the child wear as the parents drive the car to the front door of the hospital?
- A. A 5-point restraint in the back seat, facing backward
- B. A booster seat with a lap and shoulder belt in the back seat
- C. A lap belt in the back seat
- D. A lap and shoulder belt in the front seat
Correct answer: B
Rationale: A 5-year-old child riding in a car should use a restraint system for safety. The Centers for Disease Control and Prevention recommend that children under 13 years should not ride in the front seat of a car due to safety concerns. For a 5-year-old child, a booster seat with a lap and shoulder belt in the back seat is the most appropriate choice. This setup ensures proper protection and restraint for the child's size and age. Choice A is incorrect because a 5-point restraint system facing backward is not suitable for a 5-year-old child in a car. Choice C is incorrect as a lap belt alone does not provide adequate protection for a child of this age. Choice D is incorrect as children should not be seated in the front seat, especially at this young age.
4. A nurse is caring for newborn infants in a nursery when a man enters the area to take his baby back to the room. The man does not have an identification bracelet, and the nurse does not recognize him. What is the next action of the nurse?
- A. Call security and ask them to escort the man out of the nursery
- B. Ask the man to wait and check the infant's chart
- C. Ask the man to return to his room and bring an identification band
- D. Allow the man to take the baby to his room
Correct answer: C
Rationale: The safety of infants in newborn nurseries is maintained by requiring parents to wear identification bracelets to identify themselves as the rightful parents. This practice minimizes the risk of mistakenly allowing an unauthorized individual to take a baby. In this scenario, since the nurse does not recognize the man and he lacks an identification bracelet, the appropriate action is to ask him to return to his room and bring the identification band. This step ensures the proper identity verification before allowing the man to take the baby. Calling security without first verifying the man's identity may escalate the situation unnecessarily. Checking the infant's chart alone does not confirm the man's identity. Allowing the man to take the baby without proper verification poses a safety risk to the infant.
5. Which of the following bony landmarks is described as a large, blunt, irregularly shaped process found on the lateral aspect of the proximal femur?
- A. Tubercle
- B. Tuberosity
- C. Condyle
- D. Trochanter
Correct answer: D
Rationale: The correct answer is D: Trochanter. The Greater Trochanter is located on the lateral aspect of the proximal femur and is a large, blunt, irregularly shaped bony process. It serves as an important attachment site for many muscles of the legs, providing leverage and movement. Choice A, Tubercle, is a small rounded projection, usually for the attachment of a ligament or tendon. Choice B, Tuberosity, is a large rounded projection, also typically for muscle attachment. Choice C, Condyle, refers to a rounded articular surface at the end of a bone, usually involved in joints.
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