NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A client is suspected of having carbon monoxide poisoning. Which of the following symptoms are associated with this condition?
- A. Red rash across the trunk and extremities
- B. Nausea, vomiting, seizures
- C. Flushing of the face and neck
- D. Abdominal pain radiating to the back
Correct answer: B
Rationale: The correct answer is 'Nausea, vomiting, seizures.' Carbon monoxide poisoning can present with symptoms such as headache, dizziness, weakness, nausea, vomiting, and confusion. Severe cases can progress to seizures, coma, and even death. It is crucial for healthcare providers to recognize these symptoms promptly to initiate appropriate treatment. Choices A, C, and D are incorrect because a red rash, flushing of the face and neck, and abdominal pain radiating to the back are not typically associated with carbon monoxide poisoning. It is essential to be aware of the common manifestations of carbon monoxide poisoning to ensure timely intervention and prevent adverse outcomes.
2. The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct answer: C
Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. During the implementation phase, the nurse puts the care plan into action, which includes coordinating with other healthcare team members like the physical therapy department. Assessment involves data gathering, planning involves goal setting, and evaluation involves determining the attainment of client goals.
3. The Sims' position is MOST similar to the ________ position.
- A. prone
- B. lateral
- C. supine
- D. Fowler's
Correct answer: B
Rationale: The correct answer is 'lateral.' The Sims' position is characterized by the patient lying on their side with the upper knee flexed and the upper arm positioned in front of the body. This is similar to the lateral position where the patient is also lying on their side. The prone position (choice A) is when the patient lies face down, the supine position (choice C) is when the patient lies face up, and Fowler's position (choice D) is a seated position with the head of the bed elevated at a 45-90 degree angle. Therefore, the lateral position is the most similar to the Sims' position as both involve the patient lying on their side.
4. The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?
- A. "Measuring temperature using the TMT is cost-effective."?
- B. "The rapid measurement of the TMT is beneficial for uncooperative younger children."?
- C. "TMT is not recommended for measuring core body temperature in newborn infants."?
- D. "TMT is not the preferred method for measuring body temperature in patients with otitis media."?
Correct answer: B
Rationale: The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.
5. A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct answer: C
Rationale: The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams. Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.
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