NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. When a nurse's hand comes in contact with a client's blood after providing wound care, what is the next action the nurse should take?
- A. Use an alcohol-based hand sanitizer to disinfect the hands
- B. Wash hands with soap and water using appropriate technique
- C. Notify the appropriate personnel about the exposure to client's blood
- D. Sample some of the client's blood to determine the presence of diseases
Correct answer: B
Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.
2. A resident brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. What rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug?
- A. Controls stray electrical currents.
- B. Promotes efficient use of electricity.
- C. Shuts off the appliance if there is an electrical surge.
- D. Divides the electricity among the appliances in the room.
Correct answer: A
Rationale: A three-pronged plug functions as a ground to dissipate stray electrical currents. This helps prevent electrical shocks and ensures the safety of the user. Choice B is incorrect because the number of prongs on a plug does not impact the efficient use of electricity. Choice C is incorrect because a three-pronged plug does not shut off the appliance during an electrical surge; that role is typically fulfilled by surge protectors. Choice D is incorrect as a three-pronged plug does not divide electricity among appliances in a room; it primarily serves as a safety measure to handle excess electrical currents.
3. Which of the following puts the layers of skin in the correct order from right to left?
- A. Dermis, epidermis, hypodermis
- B. Hypodermis, epidermis, dermis
- C. Epidermis, dermis, hypodermis
- D. None of the above
Correct answer: C
Rationale: The correct order of the layers of skin from outermost to innermost is the epidermis, dermis, and then the hypodermis. The epidermis is the outermost layer of the skin, followed by the dermis, which is the middle layer containing connective tissue, hair follicles, and sweat glands. The hypodermis, also known as the subcutaneous tissue, lies beneath the dermis and consists of fat and connective tissue. Choice A is incorrect as it lists the layers in the reverse order. Choice B is incorrect as it reverses the order of the layers. Choice D is incorrect as there is a correct answer among the choices.
4. The NFPA diamond has four colors. The blue diamond:
- A. indicates hazards to health.
- B. designates that it is safe to use water to put out this type of fire.
- C. indicates that ice is necessary to treat an injury with this type of chemical.
- D. indicates that the chemical may be incinerated upon disposal.
Correct answer: A
Rationale: The National Fire Protection Agency (NFPA) uses a safety diamond to communicate the level of threat posed by a specific chemical. The blue diamond in the NFPA diamond system signifies potential health hazards associated with the use of that chemical. Choice B is incorrect because the blue diamond does not indicate anything about using water to extinguish fires. Choice C is incorrect as the NFPA diamond does not provide information on treating injuries. Choice D is also incorrect as the blue diamond does not suggest incineration upon disposal; it pertains to health hazards.
5. What are Korotkoff sounds?
- A. Sounds noted during diastole.
- B. The result of the vibration of blood against artery walls while blood pressure readings are being taken.
- C. Sounds only noted by skilled cardiologists.
- D. Distinct sounds which are classified into 6 phases.
Correct answer: B
Rationale: Korotkoff sounds are the sounds that occur when blood flows in an artery that has been temporarily compressed during a blood pressure measurement. These sounds result from the vibration of blood against the artery walls as the pressure cuff is released. There are five distinct phases of Korotkoff sounds, which healthcare providers are trained to identify during blood pressure assessment. The correct answer, choice B, accurately describes the nature of Korotkoff sounds and how they are generated. Choices A, C, and D are incorrect because Korotkoff sounds are not specific to diastole, not limited to skilled cardiologists, and categorized into five phases, not six.
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