NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. The Rule of Nines is used to:
- A. determine the amount of the body surface that has been burned
- B. assess the level of oxygen saturation in a body that has been burned.
- C. determine the level of tissue damage that has occurred in a burn.
- D. None of the above.
Correct answer: A
Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.
2. The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or healthcare providers, the nurse emphasizes interventions that do which of the following? (Berman & Snyder, 2012, p. 713)
- A. Eliminate the reservoir
- B. Block the portal of exit from the reservoir
- C. Block the portal of entry into the host
- D. Decrease the susceptibility of the host
Correct answer: B
Rationale: To prevent the spread of infection from a chronic carrier, the nurse should focus on blocking the portal of exit from the reservoir, which is the carrier person. By preventing the movement of the organism from the reservoir, the infection can be contained. Eliminating the reservoir is not feasible in this case as the carrier is a chronic carrier. Blocking the portal of entry into the host or decreasing the susceptibility of the host would only impact individual prevention and not the spread from the carrier to others.
3. Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?
- A. Sports and games with rules.
- B. Finger paints and water play.
- C. "Dress-up"? clothes and props.
- D. Chess and television programs
Correct answer: A
Rationale: For 7-year-old children, play serves an important role in developing cooperation, logical reasoning, and social skills. Organizing sports and games with rules is beneficial as it helps children understand the importance of rules, promotes teamwork, and fosters social interactions. Finger paints and water play, while fun, may not target the specific developmental needs of this age group. Similarly, 'Dress-up' clothes and props can encourage imaginative play but may not necessarily promote cooperation and logical reasoning. Chess and television programs are more suited for older children and may not engage 7-year-olds as effectively in developing the desired skills.
4. Which of the following is an anthropometric measurement?
- A. Blood pressure
- B. Temperature
- C. Pulse Rate
- D. Weight
Correct answer: D
Rationale: Anthropometric measurements relate to the size, weight, and proportions of the human body. Weight is a key anthropometric measurement as it directly reflects body mass, making it the correct choice. Blood pressure, temperature, and pulse rate are physiological measurements that do not specifically pertain to body size or proportion, hence making them incorrect choices in the context of anthropometric measurements.
5. What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?
- A. Will comply with the treatment prescribed.
- B. Has given up her belief in naturalistic causes of disease.
- C. May also be seeking the assistance of a shaman or medicine man.
- D. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.
Correct answer: C
Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.
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