you must wear gloves when you are
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Nursing Elites

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. When should you wear gloves?

Correct answer: B

Rationale: You must wear gloves when transferring breast milk into a baby bottle because breast milk is considered a bodily fluid. It is essential to avoid direct contact to prevent contamination. When preparing infant formula, gloves are not required as formula is not a bodily fluid. Knocking on or opening a patient's door does not involve direct contact with bodily fluids, so gloves are unnecessary in those situations.

2. A client is receiving high-dose brachytherapy as a form of cancer treatment. What type of teaching must the nurse include when educating this client about safety?

Correct answer: D

Rationale: A client undergoing high-dose brachytherapy has a radiation implant placed for cancer treatment. To ensure safety, the client should be in a private hospital room to prevent radiation exposure to others. Limiting visits from friends and family is necessary to prevent overexposure. Option A is incorrect as isolation under airborne precautions is not required for brachytherapy. Option B and C are the correct choices as they focus on minimizing radiation exposure to others, ensuring safety during treatment.

3. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?

Correct answer: A

Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.

4. During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?

Correct answer: C

Rationale: When prioritizing patient assessments, the nurse should address the patient with cirrhosis and ascites who has an elevated oral temperature of 102�F (38.8�C) first. This presentation suggests a potential infection, which is critical to address promptly in a patient with liver disease. An infection in a patient with cirrhosis can quickly progress to severe complications. The other options, such as chronic pancreatitis with abdominal pain, compensated cirrhosis with anorexia, and post-laparoscopic cholecystectomy with shoulder pain, do not indicate an immediate life-threatening situation requiring urgent assessment compared to a possible infection in a patient with cirrhosis and ascites.

5. A patient's blood pressure is 118/82 mm Hg. The patient asks the nurse, "What do the numbers mean?"? Which is the best reply by the nurse?

Correct answer: C

Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume. Both the systolic and diastolic blood pressure are important. Choice A is incorrect as providing a vague reassurance does not address the patient's query. Choice B is incorrect as it inaccurately describes the diastolic pressure as reflecting stroke volume, which is incorrect. Choice D is incorrect as it oversimplifies the explanation, focusing solely on the top number without providing a complete understanding of blood pressure.

Similar Questions

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To properly read a meniscus,

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