NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A healthcare provider attempts to plug in a sequential compression device when they notice a tingling sensation in their hands while touching the cord. What is the next action of the healthcare provider?
- A. Attempt to plug the device into a different outlet
- B. Inspect the cord for damage; if none is present, continue to use the device
- C. Discontinue the device and send it to the maintenance department for inspection
- D. Notify the supervisor that the unit is at risk of an electrical fire
Correct answer: C
Rationale: Feeling a tingling sensation when touching an electrical cord is a warning sign that the device may be malfunctioning. This sensation indicates a potential electrical current leak, which could pose a risk of harm. The correct action is to immediately discontinue the use of the device and send it to the maintenance department for inspection. Continuing to use the device without addressing the issue could lead to electric shock or fire hazards. Trying to plug the device into a different outlet does not address the underlying problem of potential device malfunction. Notifying the supervisor about the risk of an electrical fire is important, but the immediate action should be to stop using the device and have it inspected by maintenance professionals. Therefore, the best course of action is to discontinue the device and ensure it is checked thoroughly before further use.
2. Which of the following statements best describes substance P?
- A. Substance P decreases a client's sensitivity to pain
- B. Substance P levels are drawn before administration of narcotic analgesics
- C. Substance P is found in the brain and is responsible for pain control and management of depression
- D. Substance P is found in the dorsal horn of the spinal column
Correct answer: D
Rationale: Substance P is a neurotransmitter found in the brain and the dorsal horn of the spinal column, not just in the brain. It is associated with pain transmission and modulation. Substance P is known to cause inflammation, edema, and pain. While it plays a role in pain perception, it does not decrease a client's sensitivity to pain (Choice A), nor are its levels typically drawn before administering narcotic analgesics (Choice B). Although substance P is involved in pain control, it is not responsible for managing depression (Choice C). Therefore, the correct statement is that substance P is found in the dorsal horn of the spinal column.
3. The healthcare professional is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
- A. Measuring the infant's length using a tape measure
- B. Weighing the infant on an electronic standing scale
- C. Measuring the chest circumference at the nipple line with a tape measure
- D. Measuring the head circumference by wrapping the tape measure around the head
Correct answer: C
Rationale: For accurate measurements, specific techniques are required for different parameters in infants. Measuring the chest circumference involves encircling the chest at the nipple line. Length should be measured on a horizontal measuring board. Weight should be measured using a platform-type balance scale. Head circumference measurement entails ensuring the tape is aligned at the eyebrows and prominent frontal and occipital bones for the widest span. Therefore, the correct technique for measuring the chest circumference is at the nipple line with a tape measure. The other options are incorrect because length should be measured on a horizontal board, weight should be measured on a balance scale, and head circumference should be measured around the head, not over the nose and cheekbones.
4. A patient has a goal of eating at least 50% of each meal. The patient refuses to eat, so a nurse force-feeds the patient in order for them to reach their goal of eating at least 50% of the meal. The nurse has committed __________ against this patient.
- A. assault
- B. battery
- C. physical neglect
- D. emotional neglect
Correct answer: B
Rationale: The correct answer is 'battery.' Battery occurs when there is unwanted physical contact or force applied to a person without their consent. In this scenario, force-feeding the patient against their will constitutes battery as the nurse is physically interfering with the patient's body without permission. Assault involves the threat of physical harm, which is not present in the situation described. Physical neglect refers to the failure to provide basic care needs, which is not the case here. Emotional neglect involves the failure to address emotional needs, which is also not applicable in this context.
5. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?
- A. Performs the examination from both sides of the bed.
- B. Examines tender or painful areas last to help relieve the patient's anxiety.
- C. Follows a flexible examination sequence, considering the patient's age and condition.
- D. Organizes the assessment to ensure that the patient does not change positions too often.
Correct answer: D
Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.
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