NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. 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.
2. Which bloodborne pathogen is the most virulent? (Choose the BEST answer.)
- A. HCV
- B. HPV
- C. HIV
- D. HBV
Correct answer: A
Rationale: The correct answer is HCV (Hepatitis C Virus). Hepatitis C is considered the most virulent bloodborne pathogen, being 100 times more virulent than Hepatitis B. HPV (Human Papillomavirus) is a sexually transmitted infection but is not a bloodborne pathogen. HIV (Human Immunodeficiency Virus) affects the immune system but is not as virulent as Hepatitis C in terms of bloodborne transmission. HBV (Hepatitis B Virus) is less virulent compared to HCV in the context of bloodborne transmission.
3. You are working the 8 am to 4 pm shift. You begin to vomit at 3 pm and you do not think that you are able to continue working. You decide to immediately go home without notifying your RN supervisor. You have ________________.
- A. enough sick time, so this is not a problem.
- B. finished all your work, so this is not a problem.
- C. seriously abandoned the patients.
- D. seriously abused and neglected the patients.
Correct answer: D
Rationale: Patient abandonment is a serious violation that can lead to disciplinary action and immediate termination of employment. It is defined as leaving patients without proper consent from the supervisor. In this scenario, leaving work without notifying the RN supervisor and potentially leaving patients unattended is considered patient abandonment, as it compromises patient safety and care. Choices A and B are incorrect because having sick time or finishing work does not justify leaving without proper protocol. Choice D is incorrect as the scenario does not indicate abuse or neglect towards the patients.
4. A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?
- A. Rigor mortis
- B. Postmortem decomposition
- C. Algor mortis
- D. Livor mortis
Correct answer: C
Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.
5. An adult's blood pressure reads 40/20. You place the patient in a Trendelenberg position before rechecking the blood pressure. What actions will you take to position the patient correctly?
- A. lower the head of the bed and raise the foot of the bed
- B. raise the head of the bed up to about 60 to 75 degrees
- C. raise the head of the bed up to about 75 to 90 degrees
- D. raise the siderails and place the bed in the high position
Correct answer: A
Rationale: In a Trendelenberg position, used for low blood pressure, the correct action is to lower the head of the bed and raise the foot of the bed. This positioning facilitates the return of blood to the heart and helps increase blood pressure. Option B, raising the head of the bed to 60 to 75 degrees, is incorrect as it is not the Trendelenberg position. Option C, raising the head of the bed to 75 to 90 degrees, is incorrect as it does not align with the Trendelenberg position. Option D, raising the siderails and placing the bed in the high position, is incorrect as it does not address the specific positioning required for the Trendelenberg position.
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