NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. What is the initial step to take when a patient passes out at the front desk?
- A. Call 911.
- B. Initiate CPR.
- C. Shake the patient and ask if they are okay.
- D. Check for a pulse.
Correct answer: C
Rationale: The correct initial step when a patient passes out at the front desk is to shake the patient gently and ask if they are okay. This step aims to assess the patient's level of responsiveness. Checking for a pulse or initiating CPR should only be done if the patient does not respond to being shaken. Calling 911 can be the next step after assessing the patient's immediate condition and providing necessary assistance.
2. A physician's order instructs a nurse to take a temperature at the axilla. Where would the nurse place the thermometer?
- A. In the rectum
- B. In the mouth
- C. On the temples
- D. In the armpit
Correct answer: A
Rationale: When a physician's order specifies taking a temperature at the axilla, the nurse should place the thermometer in the armpit. The axilla is the anatomical area of the armpit located under the arms, proximal to the trunk. Placing the thermometer in the rectum (Choice A) is used for rectal temperature measurements, in the mouth (Choice B) for oral temperature measurements, and on the temples (Choice C) is not a common site for temperature assessment. Therefore, the correct placement based on the given instruction is in the armpit.
3. The UAP who has just been accepted to nursing school says to a client, 'You must be so pleased with your progress.' The nurse later explains to the UAP that this is an example of what type of question?
- A. Close-ended question
- B. Open-ended question
- C. Leading question
- D. Neutral question
Correct answer: C
Rationale: The statement 'You must be so pleased with your progress' is an example of a leading question. Leading questions guide the respondent towards a particular answer or response, potentially biasing the data collected. In this scenario, the UAP's question implies that the client should be pleased with their progress, steering the client's response. Closed-ended questions typically elicit brief factual responses or a 'yes' or 'no.' Open-ended questions encourage clients to provide detailed responses and share their thoughts and feelings freely. Neutral questions do not lead or influence the client's response, allowing for unbiased information gathering.
4. How many cc are there in 25 ounces?
- A. 250
- B. 500
- C. 750
- D. 1000
Correct answer: C
Rationale: To convert ounces to cc, we know that there are 30 cc in 1 ounce. Therefore, to find out how many cc are in 25 ounces, we multiply 30 cc/ounce by 25 ounces which equals 750 cc. This makes choice C, 750, the correct answer. Choices A, B, and D are incorrect as they do not correctly convert ounces to cc.
5. The body system that functions to maintain fluid balance, support immunity, and contains the spleen is the:
- A. Lymphatic System
- B. Digestive System
- C. Urinary System
- D. Respiratory System
Correct answer: A
Rationale: The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.
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