NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. What is the first aid for frostbite?
- A. Running cold water over the affected area. Warm or hot water will shock the area and cause more tissue damage.
- B. Run warm water over the area to rapidly rewarm the affected area.
- C. Run hot water over the area to warm the area as quickly as possible.
- D. Cover the area with a blanket, using a heating pad if the blanket isn't warm enough.
Correct answer: A
Rationale: First aid for frostbite involves running cold water over the affected area. It is important to avoid warm or hot water as it can shock the area and cause further tissue damage. Warm water should not be used to rapidly rewarm the affected area. Similarly, hot water should also be avoided as it can warm the area too quickly and potentially cause harm. Covering the area with a blanket and using a heating pad may not be effective and can even lead to more damage. Seeking medical assistance is crucial if the tissue appears necrotic to prevent further complications.
2. The healthcare professional is preparing to auscultate the abdomen. How should they proceed?
- A. Warm the endpiece of the stethoscope by rubbing it between their hands.
- B. Ensure the patient is adequately covered and comfortable during the examination.
- C. Ensure that the diaphragm side of the stethoscope is in use.
- D. Check the room temperature and offer blankets to the patient if needed.
Correct answer: D
Rationale: When preparing to auscultate the abdomen, it is important to ensure the patient's comfort. The room should be warm to prevent shivering, which can interfere with sound clarity. Offering blankets to the patient if they feel cold helps maintain their comfort during the examination. The endpiece of the stethoscope should be warmed by rubbing it between the examiner's hands, not by placing it in warm water. It is important to use the diaphragm, not the bell, of the stethoscope to auscultate for bowel sounds. Therefore, choice D is the correct answer, as it addresses the patient's comfort and the room temperature, which are essential for a successful abdominal auscultation.
3. All of the following factors may contribute to client falls EXCEPT:
- A. Contact dermatitis
- B. Urinary frequency
- C. Decreased visual acuity
- D. Confusion
Correct answer: A
Rationale: Client falls can result from various factors, both intrinsic and extrinsic. Intrinsic factors include health conditions like urinary frequency, which increases the need for bathroom visits, decreased visual acuity, and confusion. These factors can directly contribute to an increased risk of falls. However, contact dermatitis does not directly lead to falls. Contact dermatitis is a skin condition caused by contact with irritants or allergens and does not inherently predispose individuals to falling. Therefore, among the given options, contact dermatitis is the only factor that is not directly associated with an increased risk of falls.
4. A patient in a clinic has been diagnosed with hepatitis A. What is the most likely route of transmission?
- A. Sexual contact with an infected partner
- B. Contaminated food
- C. Blood transfusion
- D. Illegal drug use
Correct answer: B
Rationale: The correct answer is contaminated food. Hepatitis A is primarily transmitted through the fecal-oral route, often through the ingestion of contaminated food or water. It is caused by the Hepatitis A virus (HAV), which is a single-stranded, positive-sense RNA virus. Sexual contact with an infected partner is more commonly associated with hepatitis B and C. Blood transfusion is a potential route for hepatitis B and C transmission due to bloodborne pathogens. Illegal drug use, particularly involving shared needles, is a common route for hepatitis C transmission.
5. The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?
- A. Prone position
- B. Supine with no head elevation
- C. Side-lying with the legs extended
- D. Supine with the head elevated 45 degrees
Correct answer: A
Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site. Therefore, the correct choice is the prone position for this postoperative care scenario.
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