NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Which of the following is the correct sequence for removing personal protective equipment?
- A. Remove gown, gloves, shoe covers, mask
- B. Remove mask, gloves, gown, shoe covers
- C. Remove gloves, gown, mask, shoe covers
- D. Remove shoe covers, mask, gloves, gown
Correct answer: C
Rationale: The correct sequence for removing personal protective equipment is crucial to prevent contamination. When exiting a surgical or aseptic situation, the proper sequence is to first remove gloves, followed by the gown, mask, and finally shoe covers. This order ensures that potentially contaminated items are removed first, minimizing the risk of exposure. Choice A, 'Remove gown, gloves, shoe covers, mask,' is incorrect as gloves should be removed before the gown. Choice B, 'Remove mask, gloves, gown, shoe covers,' is incorrect as gloves should be removed first. Choice D, 'Remove shoe covers, mask, gloves, gown,' is incorrect as gloves should be the first item removed to prevent contamination.
2. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?
- A. "Are you of the Christian faith?"?
- B. "Do you want to see a medicine man?"?
- C. "How often do you seek help from medical providers?"?
- D. "What cultural or spiritual beliefs are important to you?"?
Correct answer: D
Rationale: The nurse needs to assess the cultural beliefs and practices of the patient and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication. Therefore, the most appropriate question to initiate an assessment of cultural beliefs with an older American Indian patient is "What cultural or spiritual beliefs are important to you?"? This question shows respect for the patient's beliefs and encourages them to share relevant information. Asking if they are of the Christian faith does not promote open communication and may not reflect the patient's actual beliefs. While some American Indians may seek assistance from a medicine man or shaman, it is not appropriate to make assumptions without direct input from the patient. Asking how often they seek help from medical providers is not directly related to understanding their cultural beliefs and may not provide relevant insights for culturally competent care.
3. Digestion, elimination, and ___________ are the three functions of the digestive system.
- A. constriction
- B. relaxation
- C. absorption
- D. peristalsis
Correct answer: C
Rationale: The correct answer is 'absorption.' The three main functions of the digestive system are digestion, absorption, and elimination. Absorption refers to the process of absorbing nutrients and other substances from the digested food into the bloodstream. Choices A, B, and D are incorrect: Constriction is not a primary function of the digestive system, relaxation is not a distinct function in this context, and peristalsis is a muscular movement that aids in digestion but is not one of the three main functions of the digestive system.
4. A healthcare provider attempts to plug in a sequential compression device when they notice a tingling sensation in their hands while touching the cord. What is the next action of the healthcare provider?
- A. Attempt to plug the device into a different outlet
- B. Inspect the cord for damage; if none is present, continue to use the device
- C. Discontinue the device and send it to the maintenance department for inspection
- D. Notify the supervisor that the unit is at risk of an electrical fire
Correct answer: C
Rationale: Feeling a tingling sensation when touching an electrical cord is a warning sign that the device may be malfunctioning. This sensation indicates a potential electrical current leak, which could pose a risk of harm. The correct action is to immediately discontinue the use of the device and send it to the maintenance department for inspection. Continuing to use the device without addressing the issue could lead to electric shock or fire hazards. Trying to plug the device into a different outlet does not address the underlying problem of potential device malfunction. Notifying the supervisor about the risk of an electrical fire is important, but the immediate action should be to stop using the device and have it inspected by maintenance professionals. Therefore, the best course of action is to discontinue the device and ensure it is checked thoroughly before further use.
5. A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?
- A. Refer the infant to a physician for further evaluation.
- B. Consider these findings normal for a 1-month-old infant.
- C. Expect the chest circumference to be greater than the head circumference.
- D. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
Correct answer: B
Rationale: In infants, a normal head measurement is approximately 32 to 38 cm, and it is usually around 2 cm larger than the chest circumference. These measurements vary with age; between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference becomes greater than the head circumference. Given that the 1-month-old infant's head measurement is within the typical range and slightly larger than the chest circumference, the nurse should consider these findings normal. There is no indication to refer the infant for further evaluation or to have the parent return for re-evaluation in 2 weeks, as these measurements fall within the expected parameters for a 1-month-old infant.
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