NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. When educating a client about their new prescription for warfarin, what should the nurse advise?
- A. To have his white blood cell count tested once a month
- B. To avoid any activities that could lead to injury
- C. To avoid eating leafy green vegetables
- D. Both A and B
Correct answer: B
Rationale: The correct answer is to advise the client to avoid any activities that could lead to injury when taking warfarin. Warfarin is an anticoagulant medication that decreases blood clotting, increasing the risk of bleeding. Engaging in activities that may result in injury can lead to uncontrolled bleeding, which can be serious. While monitoring white blood cell count is not specifically related to warfarin therapy, avoiding leafy green vegetables is important due to their vitamin K content, which can interfere with warfarin's effectiveness. Therefore, the client should be educated to avoid activities that could cause injury to prevent potential bleeding complications.
2. A client has become combative and is attempting to pull out his IV and take off his surgical dressings. The nurse receives an order to apply wrist restraints. Which action of the nurse signifies that restraints are being used safely?
- A. The nurse ties the restraints in a square knot to prevent the client from untying them
- B. The restraints are attached to a movable portion of the bed
- C. The padded side of the restraint is applied next to the skin of the wrist
- D. The nurse assesses the client's distal circulation every 24 hours
Correct answer: C
Rationale: Restraint use must prioritize the safety of the client. When applying restraints around the wrists, the padded side should be placed against the skin to help prevent skin breakdown. Additionally, restraints should be secured in quick-release knots to ensure they can be removed rapidly in case of an emergency. Choice A is incorrect as restraints should not be tied in a way that could prevent quick removal. Choice B is incorrect because restraints should not be attached to a movable part of the bed to avoid unintentional movement. Choice D is incorrect as assessing distal circulation is important but is not directly related to the safe application of restraints.
3. A client is being assisted with ambulation in the hallway using a gait belt when they become dizzy and start to faint. What is the first action the nurse should take?
- A. Stand behind the client and prepare to catch them if they fall
- B. Assist the client to sit in the nearest chair or slide down along a wall
- C. Grasp the client under the arms and pull them upward
- D. Call for help from nearby staff
Correct answer: A
Rationale: If a client becomes dizzy and starts to faint while being assisted with ambulation, the nurse's first action should be to assist the client into a sitting position to prevent or reduce the impact of a fall. This can be done by guiding the client to sit in the nearest chair or sliding down along a wall for support. Option A is incorrect because standing behind the client may not prevent a fall and could potentially lead to injury. Option C is incorrect as pulling the client upward may worsen the situation. Option D, calling for help, is not the first action to take when the client is at risk of falling.
4. A patient's Foley catheter has been discontinued. You will dispose of this patient equipment by doing which of the following?
- A. Wearing gloves and then placing this equipment in the regular trash can after it is placed in a paper bag.
- B. Simply placing this equipment in the regular trash can after it is placed in a paper bag.
- C. Wearing gloves and then placing this equipment into a special 'hazardous waste' container.
- D. Simply placing this equipment in the 'hazardous waste' container after it is placed in a paper bag.
Correct answer: C
Rationale: When disposing of used patient equipment, such as a Foley catheter, that has come in contact with bodily fluids, it is considered hazardous waste. The correct procedure involves wearing gloves and placing the Foley bag and tubing into a special 'hazardous waste' container. This container is marked as 'Hazardous' and is typically red to indicate the potential danger of its contents. Placing the equipment in a regular trash can, even if placed in a paper bag, is not appropriate as it does not meet the standards for disposing of hazardous waste. Therefore, options A and B are incorrect. Similarly, simply placing the equipment in a 'hazardous waste' container after it is placed in a paper bag is also incorrect as direct disposal into the designated container while wearing gloves is the proper protocol, making option D incorrect.
5. What is the minimum amount of personal protective equipment for a nurse when working with a newborn immediately after a high-risk delivery in a client's room?
- A. Sterile gown, gloves
- B. Mask, gown, shoe covers
- C. Gloves
- D. Hat, mask, gloves, gown, shoe covers
Correct answer: C
Rationale: The correct answer is gloves. When attending a high-risk delivery and handling a newborn immediately after birth, the minimum personal protective equipment required for a nurse includes gloves. This is essential to protect the nurse from potential exposure to the mother's blood or body fluids that may be present on the newborn's skin. Choices A, B, and D include additional protective equipment that is not necessary for this specific scenario. Wearing gloves is crucial for infection control and to prevent the transmission of pathogens.
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