NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Which of the following is an example of an environmental hazard that may put the healthcare professional at risk of injury?
- A. Loud noise from the hospital maintenance system
- B. Airborne powder containing latex
- C. Chemicals containing ethylene oxide
- D. All of the above
Correct answer: D
Rationale: Healthcare professionals, including nurses, are exposed to various environmental hazards that may negatively impact their physical or mental health. Hazards come in several forms, such as loud noise from hospital systems, which can damage hearing; airborne latex powder, leading to allergic reactions; and chemicals like ethylene oxide, a sterilizing agent that can cause cancer. Therefore, all the options listed pose risks to healthcare professionals, making 'All of the above' the correct answer. Choice A, loud noise, is a hazard that can affect hearing health. Choice B, airborne latex powder, can trigger allergic responses. Choice C, chemicals containing ethylene oxide, are hazardous and can lead to serious health issues. Each option represents a distinct environmental risk that healthcare professionals should be aware of and take precautions against.
2. A client is being transferred from a bed to a wheelchair. Which action is essential to maintain client safety in this situation?
- A. Position the wheelchair at the foot of the bed
- B. Maintain a space of at least 12 inches between the wheelchair and the bed
- C. Place the footplates in the lowest position before transferring the client
- D. Lock both wheels on the wheelchair before moving the client
Correct answer: D
Rationale: When transferring a client from a bed to a wheelchair, it is crucial to prioritize client safety. Locking both wheels on the wheelchair before moving the client is essential as it adds stability and prevents the wheelchair from moving unexpectedly during the transfer process. Placing the wheelchair at the foot of the bed allows for easier transfer, but ensuring the wheels are locked is more critical for safety. Maintaining a 12-inch space between the wheelchair and the bed is not as essential as ensuring wheel locks are engaged. While placing the footplates in the lowest position can enhance client comfort, it is not a safety measure that is as critical as securing the wheelchair by locking its wheels before the transfer.
3. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?
- A. Help client into the chair more quickly
- B. Document client's vital signs taken just prior to moving the client
- C. Help client back to bed immediately
- D. Observe client's skin color and take another set of vital signs
Correct answer: D
Rationale: In this scenario, the nurse has observed concerning signs in the client during the transfer process. The appropriate action for reassessment would be to observe the client's skin color and take another set of vital signs. This will provide essential data to evaluate the client's condition more accurately. Options A, B, and C are interventions that do not address the need for reassessment. Moving the client more quickly, documenting previous vital signs, or returning the client to bed do not directly address the need to reassess the client's current condition.
4. A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?
- A. The client most likely has a mental illness that should be treated before addressing sleep issues
- B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
- C. The client may become tired once they start talking
- D. None of the above
Correct answer: B
Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.
5. When cleansing the genital area during perineal care, the nurse should _____________.
- A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
- B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
- C. cleanse the rectal area first and then clean the patient's genital area.
- D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.
Correct answer: B
Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.
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