NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A patient is bleeding profusely from an injury near her wrist. Which of the following first aid procedures would be MOST appropriate?
- A. Place a tourniquet on her arm above the injury.
- B. Place pressure on her brachial artery.
- C. Place pressure on her radial nerve.
- D. Cover the bleeding area with wet towels.
Correct answer: B
Rationale: The most appropriate first aid procedure for a patient bleeding profusely from an injury near the wrist is to place pressure on her brachial artery. Applying pressure to the brachial pulse point will help slow down the bleeding. Placing a tourniquet on her arm above the injury is not recommended as it could potentially inhibit blood flow, leading to tissue necrosis. Pressing on the radial nerve or covering the bleeding area with wet towels are not effective in controlling bleeding and may not address the underlying cause.
2. Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness liquids for her. Water is not a honey thickness liquid. It is much thinner. What should you do?
- A. Tell the resident that she cannot have water.
- B. Give her applesauce instead of the water.
- C. Tell Cheryl that she is NPO until midnight.
- D. Thicken the water and give it to her.
Correct answer: D
Rationale: You can give Cheryl the water that she has requested; however, since water is not a honey-thick liquid as ordered by the doctor, you must thicken it with a commercial thickener before giving it to her. This will ensure that the water is at the appropriate consistency for her swallowing disorder. Choices A, B, and C are incorrect: A) Telling the resident she cannot have water is not the best course of action without attempting to modify it first. B) Giving her applesauce instead of water does not address the specific request for water. C) Placing Cheryl on NPO status until midnight is unnecessary and does not address her immediate request for water.
3. A client has just started a transfusion of packed red blood cells that a physician ordered. Which of the following signs may indicate a transfusion reaction?
- A. The client suddenly complains of back pain and has chills
- B. The client develops dependent edema in the extremities
- C. The client has a seizure
- D. The client's heart rate drops to 60 bpm
Correct answer: A
Rationale: The correct answer is when the client suddenly complains of back pain and has chills. Signs of a transfusion reaction include back pain, chills, dizziness, increased temperature, and blood in the urine. These signs indicate a possible adverse reaction to the blood transfusion. Dependent edema in the extremities is not typically associated with a transfusion reaction. A seizure is not a common sign of a transfusion reaction unless it is due to severe complications. A decrease in heart rate to 60 bpm is not a typical sign of a transfusion reaction, but rather bradycardia may indicate other underlying conditions or medications.
4. Which of the following is a fat-soluble vitamin?
- A. Vitamin C
- B. Vitamin D
- C. Vitamin B-6
- D. Riboflavin
Correct answer: B
Rationale: The correct answer is Vitamin D. Fat-soluble vitamins are those that can be stored in the body, allowing excess amounts to be stored for later use. While this storage ability can help prevent deficiencies, it also poses a risk of toxicity. The fat-soluble vitamins are A, E, D, and K. Choice A, Vitamin C, is water-soluble, not fat-soluble. Choice C, Vitamin B-6, and Choice D, Riboflavin, are also water-soluble vitamins and not fat-soluble.
5. The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory?
- A. The causation of illness is based on supernatural forces that influence the humors of the body.
- B. Herbs and medicines are classified based on their physical characteristics of hot and cold and the humors of the body.
- C. The four humors of the body consist of blood, yellow bile, black bile, and phlegm.
- D. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.
Correct answer: D
Rationale: The hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile, and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness, and moisture. The treatment of disease in this theory involves adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. Choice A is incorrect as the theory is not based on supernatural forces but on the balance of bodily humors. Choice B is incorrect as herbs and medicines are not classified solely based on their physical characteristics of hot and cold in this theory. Choice C is incorrect as the four humors are blood, phlegm, black bile, and yellow bile, not spiritual connectedness or social aspects. Therefore, the correct choice is D, as it accurately reflects a foundational tenet of the hot/cold theory of health and illness.
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