NCLEX NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. You are taking care of a patient who has active TB. The patient has been put on airborne precautions and is in a special room. You must wear a HEPA mask when you enter the room. Now, the patient has to leave the room and go to the radiology department. How can you transport this patient to the radiology department without spreading TB throughout the hospital?
- A. Have everyone along the route to the radiology department wear a HEPA mask.
- B. Have patients along the route to the radiology department wear a HEPA mask.
- C. Have staff along the route to the radiology department wear a HEPA mask.
- D. Place a HEPA mask on the patient.
Correct answer: Place a HEPA mask on the patient.
Rationale: To prevent the spread of TB throughout the hospital, it is essential to place a HEPA mask on the patient before transporting them to the radiology department. Expecting everyone along the route to wear a HEPA mask is not practical due to the high cost and the need for special fittings. Having patients or staff wear HEPA masks along the route is also not feasible and may not effectively contain the spread of TB.
2. When counting an infant’s respirations, which technique is correct?
- A. Watching the chest rise and fall
- B. Observing the movement of the abdomen
- C. Placing a hand across the infant’s chest
- D. Using a stethoscope to listen to the breath sounds
Correct answer: Observing the movement of the abdomen
Rationale: The correct technique for counting an infant's respirations is to observe the movement of the abdomen. Infants typically have more diaphragmatic breathing than thoracic, so watching the abdomen provides a more accurate count. Placing a hand on the chest or listening with a stethoscope can alter the infant's breathing pattern and provide inaccurate results. Therefore, options A, C, and D are incorrect methods for counting an infant's respirations. By observing the movement of the abdomen, healthcare providers can accurately assess an infant's respiratory rate without influencing their breathing pattern.
3. Which of the following types of dressing changes works as a form of wound debridement?
- A. Dry dressing
- B. Transparent dressing
- C. Composite dressing
- D. Wet to dry dressing
Correct answer: Wet to dry dressing
Rationale: The correct answer is 'Wet to dry dressing.' Wet to dry dressing is a method of wound debridement that involves applying sterile soaked gauze to the wound, allowing it to dry and stick to the wound. When the dressing is removed, it pulls away drainage and debris, aiding in wound debridement. Choice A, 'Dry dressing,' does not actively assist in debridement as it does not collect or remove debris from the wound. Choice B, 'Transparent dressing,' is primarily used for maintaining a moist environment and wound observation, not for debridement. Choice C, 'Composite dressing,' combines multiple layers for different wound care purposes but is not specifically designed for debridement like wet to dry dressing.
4. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
- A. Only refer to the client by gender
- B. Identify the client only by age
- C. Avoid using the client's name
- D. Discuss the client another time
Correct answer: Discuss the client another time
Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification. Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.
5. Which characteristic usually results in a behavior being viewed and accepted as normal?
- A. Fits within standards accepted by one’s society
- B. Helps the person reduce the need for coping skills
- C. Allows the person to express feelings and thoughts
- D. Facilitates achievement of short-term and long-term goals
Correct answer: Fits within standards accepted by one’s society
Rationale: Behaviors that align with the standards accepted by a society are generally viewed as normal. Societal norms and values play a significant role in defining what is considered normal behavior. Choices B, C, and D may be important aspects of an individual's functioning, but they do not solely determine whether a behavior is viewed as normal. Coping skills, expressions of feelings, and goal achievement can vary in their cultural context and societal acceptance, therefore they are not definitive indicators of normalcy.
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