NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. What is the primary purpose of emergency planning?
- A. Comply with the laws of the state.
- B. Comply with the laws of the U.S.
- C. Comply with both state and U.S. laws
- D. Maintain safety
Correct answer: D
Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.
2. After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods?
- A. Return demonstration
- B. Explanation
- C. Achievement of 90 on written test
- D. Have the client explain the procedure to the family
Correct answer: A
Rationale: After teaching the client on crutch walking technique, assessing the client's understanding is crucial. The most effective method to evaluate the client's comprehension of a hands-on skill like crutch walking technique is through a return demonstration. This allows the nurse to observe the client performing the technique, ensuring they have grasped the instructions correctly and can execute the skill safely. While providing an explanation can help clarify doubts, it may not confirm the client's ability to perform the skill. Achieving a high score on a written test assesses cognitive understanding but not necessarily the practical application of the skill. Having the client explain the procedure to the family does not directly assess their ability to perform the skill themselves; it tests their ability to communicate the information to others.
3. According to the American Heart Association standards, high-quality CPR for an adult includes all of the following EXCEPT:
- A. Push hard
- B. Push fast
- C. Allow chest recoil between compressions
- D. Pause CPR as each drug is administered
Correct answer: D
Rationale: High-quality CPR for adults should not be paused for drug administration. The correct CPR technique involves pushing hard and fast, at a rate of at least 100 compressions per minute and to a depth of at least 2 inches. It is also essential to allow chest recoil between compressions to enable proper blood circulation. Pausing CPR for drug administration would delay the delivery of continuous chest compressions, which are crucial for maintaining blood flow and oxygenation during cardiac arrest.
4. While performing the physical examination, why does the nurse share information and briefly teach the patient?
- A. To help the patient feel more comfortable and gain control of the situation
- B. To build rapport and increase the patient's confidence in the examiner
- C. To assist the patient in understanding his or her disease process and treatment modalities
- D. To aid the patient in identifying questions about his or her disease and potential areas of needed education
Correct answer: B
Rationale: Sharing information and briefly teaching the patient during a physical examination helps build rapport and increase the patient's confidence in the examiner. This approach gives the patient a sense of control in a situation that can often be overwhelming. While sharing information may make the patient feel more comfortable, the primary goal is to enhance the patient's confidence in the examiner. Providing information does not necessarily directly assist the patient in understanding their disease process and treatment modalities, as this may require a more in-depth explanation. The main focus is on establishing a trusting relationship and empowering the patient during the examination, rather than solely aiding in identifying questions or areas needing education.
5. 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.
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