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. In a patient with acromegaly, which assessment finding will the nurse expect to find?
- A. Sternal deformity and hyperextensible joints
- B. Growth retardation and a delayed onset of puberty
- C. Overgrowth of bone in the face, head, hands, and feet
- D. Increased height and weight and delayed sexual development
Correct answer: C
Rationale: Acromegaly is a condition characterized by excessive secretion of growth hormone in adulthood after normal body growth completion. This hormonal excess leads to overgrowth of bones in the face, head, hands, and feet; however, there is no significant change in height. Stating sternal deformity and hyperextensible joints is incorrect as they are characteristic findings of Marfan syndrome. Growth retardation and delayed onset of puberty are not typical of acromegaly but are seen in hypopituitary dwarfism. Increased height, weight, and delayed sexual development are features of gigantism, not acromegaly. Therefore, the correct assessment finding in a patient with acromegaly would be overgrowth of bone in the face, head, hands, and feet.
3. What is the most important step that healthcare personnel can take to prevent the transmission of microorganisms in the hospital setting?
- A. Wear protective eyewear at all times.
- B. Wear gloves whenever in direct contact with patients.
- C. Wash hands before and after contact with each patient.
- D. Clean the stethoscope with an alcohol swab between patients.
Correct answer: C
Rationale: The most crucial step in preventing the transmission of microorganisms in the hospital setting is proper hand hygiene. Healthcare personnel should wash their hands thoroughly before and after each patient contact to reduce the risk of spreading infections. While cleaning the stethoscope with an alcohol swab between patients is recommended, it is secondary to hand hygiene. Wearing protective eyewear at all times is not necessary for routine patient care unless specifically indicated, and wearing gloves only when in direct contact with patients is important but not as critical as proper handwashing. Therefore, the correct answer is to wash hands before and after contact with each patient.
4. A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at the time of admission?
- A. Place a padded tongue depressor at the head of the bed.
- B. Pad the bed with blankets.
- C. Inform the client about the importance of wearing a medical identification tag.
- D. Teach the client about seizures.
Correct answer: B
Rationale: The most essential measure when admitting a client who had a seizure is to pad the bed with blankets (Option B). This is crucial to prevent injury in case of another seizure. Placing a padded tongue depressor at the head of the bed (Option A) is incorrect as current nursing guidelines advise against putting anything in the client's mouth during a seizure. Informing the client about wearing a medical identification tag (Option C) and teaching the client about seizures (Option D) are important but are more relevant once the cause of the seizure is known. It's crucial to remember that not all seizures are classified as epilepsy.
5. Which of the following items of subjective client data would be documented in the medical record by the nurse?
- A. Client's face is pale
- B. Cervical lymph nodes are palpable
- C. Nursing assistant reports client refused lunch
- D. Client feels nauseated
Correct answer: D
Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.
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