NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. One of your patients is dependent on a mechanical ventilator for their respiratory needs. The patient cannot breathe on their own. Suddenly, the lights in the patient's room and the entire nursing unit go off. You realize that the electric power has been lost. What is the first thing that you should do for this patient?
- A. Plug the ventilator into the red outlet in the room.
- B. Plug the ventilator into the blue outlet in the room.
- C. Use an Ambu bag to ventilate the patient.
- D. Call the doctor about this emergency.
Correct answer: B
Rationale: In healthcare facilities, emergency generators are in place in case of power outages. The red outlets in patient rooms are connected to the emergency generator and provide power during such situations. By plugging the ventilator into the red outlet, you ensure that the patient's mechanical ventilation needs are met despite the power loss. Using an Ambu bag or calling the doctor should be secondary actions after ensuring the ventilator is powered correctly. Plugging the ventilator into the blue outlet is incorrect and can result in the ventilator not functioning during a power outage.
2. Which of the following organs would be described as being located retroperitoneally?
- A. Kidneys
- B. Thymus
- C. Small Intestines
- D. Spleen
Correct answer: A
Rationale: The term 'retroperitoneal' refers to organs positioned behind the peritoneum. The kidneys are retroperitoneal organs, located outside the peritoneal cavity, against the posterior abdominal wall. This positioning provides them with additional protection from external forces due to the surrounding structures. The thymus, small intestines, and spleen are not retroperitoneal organs. The thymus is located in the mediastinum, the small intestines are intraperitoneal, and the spleen is intraperitoneal and located in the left upper quadrant of the abdomen.
3. When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
- A. 200/92
- B. 200/100
- C. 100/200/92
- D. 200/100/92
Correct answer: A
Rationale: When auscultating blood pressure, it is crucial to note the points at which Korotkoff sounds change. In adults, the last audible sound indicates the diastolic pressure. In this case, the Korotkoff sounds muffle at 100 mm Hg and disappear at 92 mm Hg. Therefore, the blood pressure should be recorded as systolic/diastolic, which is 200/92. Choices B, C, and D are incorrect because they do not reflect the correct points where the Korotkoff sounds change during blood pressure measurement.
4. What is the MOST ACCURATE statement regarding the ESR test?
- A. The results are diagnostic for certain conditions.
- B. Abnormal results are indicative of a potentially fatal illness.
- C. Abnormal results should be followed by additional testing.
- D. Results are reported in millimeters per hour.
Correct answer: C
Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.
5. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when assessing a patient?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct answer: A
Rationale: The correct answer is Palpation. Palpation involves using the sense of touch to assess texture, temperature, moisture, and swelling in a patient. This technique allows the nurse to feel for abnormalities and changes in the patient's tissues. Inspection primarily relies on visual assessment, while percussion involves tapping on the body to produce sounds and assess underlying structures. Auscultation, on the other hand, involves listening to sounds within the body using a stethoscope. Therefore, in the context of assessing texture, temperature, moisture, and swelling, palpation is the most appropriate technique.
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