you are taking care of a patient who has active tb the patient has been put on airborne precautions the patient is in a special room you must wear a h

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. You are taking care of a patient who has active TB. The patient has been put on airborne precautions and is in a special room. You must wear a HEPA mask when you enter the room. Now, the patient has to leave the room and go to the radiology department. How can you transport this patient to the radiology department without spreading TB throughout the hospital?

A. Have everyone along the route to the radiology department wear a HEPA mask.
B. Have patients along the route to the radiology department wear a HEPA mask.
C. Have staff along the route to the radiology department wear a HEPA mask.
D. Place a HEPA mask on the patient.

Correct answer: D

Rationale: To prevent the spread of TB throughout the hospital, it is essential to place a HEPA mask on the patient before transporting them to the radiology department. Expecting everyone along the route to wear a HEPA mask is not practical due to the high cost and the need for special fittings. Having patients or staff wear HEPA masks along the route is also not feasible and may not effectively contain the spread of TB.

2. When assisting a client with shampooing his hair while he is still in bed, a nurse raises the bed to approximately the level of her waist. What is the rationale for this action?

A. To prevent shampoo from getting into the client's eyes
B. To allow excess water to run off the edge of the bed
C. To decrease strain on the nurse's back
D. To prevent the client's hair from developing tangles

Correct answer: C

Rationale: Raising the bed to the level of the nurse's waist while assisting a client with shampooing in bed is done to reduce strain on the nurse's back. This adjustment ensures that the nurse can work comfortably without excessive bending or stooping, thus preventing back injuries. Choices A, B, and D are incorrect. While preventing shampoo from getting into the client's eyes, allowing excess water to run off the bed, and preventing hair tangles are important considerations, the primary rationale for raising the bed is to prioritize the nurse's ergonomic safety and prevent musculoskeletal strain.

3. Which of the following situations indicates the need to file an incident report?

A. The neon sign directing parking for visitors has burned out
B. A nurse must send a syringe pump to maintenance for annual service
C. A client's blood pressure dropped to 90/55 after receiving a dose of morphine
D. A client's spouse becomes angry and is asked to leave the premises

Correct answer: D

Rationale: An incident report is necessary for documenting unexpected events that occur in a healthcare setting. Situations that warrant filing an incident report include client accidents, medication errors, security problems, or disruptive behaviors that involve clients, families, or visitors. In this scenario, when a client's spouse displays disruptive behavior and is asked to leave the premises, it is essential to document this incident to ensure a record of the event and its resolution. Choices A, B, and C do not involve disruptive behavior or safety concerns that would require an incident report to be filed.

4. When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?

A. 10
B. 15
C. 20
D. 30

Correct answer: D

Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion. Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.

5. Patients have a right to ______________.

A. only enough information so they can comply with care
B. ALL of their health-related information
C. small amounts of information so they do not get nervous
D. moderate amounts of information unless they are old

Correct answer: B

Rationale: Patients have a legal right to access all of their health-related information. This includes details about their health condition, treatment options, test results, and any other relevant data. Providing patients with all their health-related information empowers them to make informed decisions about their care, promotes transparency in the healthcare process, and respects their autonomy. Choices A, C, and D are incorrect because they restrict the information patients should receive based on assumptions or limitations, which goes against the principle of patient autonomy and their right to access their complete health-related information.