NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Your patient who had AIDS/HIV has just died. Should you still use standard precautions as you provide post-mortem care?
- A. Yes, because the virus is still transmissible
- B. Yes, because respect must still be maintained
- C. No, because the virus is no longer transmissible
- D. No, because it is disrespectful
Correct answer: A
Rationale: Yes, you should still use standard precautions even after an HIV/AIDS patient has died. The virus can remain infectious after death, and healthcare workers need to protect themselves from potential exposure. Choice B is incorrect because while respect is important, the primary reason for using standard precautions is to prevent transmission of infectious diseases. Choice C is incorrect as the virus can still be transmissible even after the patient's death. Choice D is incorrect as using standard precautions is a matter of infection control, not a question of respect.
2. 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.
3. A healthcare professional is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?
- A. Patient who is receiving chemotherapy for liver cancer
- B. Patient who is receiving chemotherapy for lung cancer
- C. Patient who has a wound infection after cholecystectomy
- D. Patient who requires pain management for chronic pancreatitis
Correct answer: D
Rationale: The patient with chronic pancreatitis is the best choice to admit to the same room as a patient who had a liver transplant and is experiencing acute rejection. This is because the patient with chronic pancreatitis does not pose an infection risk to the immunosuppressed patient who had a liver transplant. On the other hand, patients receiving chemotherapy for cancer or those with wound infections are at risk for infections, which could endanger the immunosuppressed patient with acute rejection.
4. Which of the following activities would the nurse perform during the diagnosing phase of the nursing process? Select all that apply.
- A. Collect and organize client information
- B. Analyze data
- C. Identify problems, risks, and client strengths
- D. Develop nursing diagnoses
Correct answer: B
Rationale: During the diagnosing phase of the nursing process, the nurse analyzes the collected data to identify problems, risks, and client strengths, which then leads to developing nursing diagnoses. Collecting and organizing client information is part of the assessment phase, where data is gathered. Developing nursing diagnoses comes after data analysis in the diagnosing phase. Goal setting is a component of the planning phase, which follows the diagnosing phase.
5. A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This situation illustrates which concept?
- A. Integration
- B. Assimilation
- C. Biculturalism
- D. Heritage consistency
Correct answer: B
Rationale: Assimilation is a unidirectional, linear process moving from unacculturated to acculturated, in which a person develops a new cultural identity and becomes like members of the dominant culture. In this scenario, the woman has adapted to the new culture by learning the language, dressing like her peers, and expressing that her family in Europe would hardly recognize her. This aligns with the process of assimilation. Integration and biculturalism, on the other hand, involve bidirectional and bidimensional processes that induce reciprocal change in both cultures while maintaining aspects of the original culture in one's ethnic identity. Since there is no indication in the question that the woman has retained aspects of her original culture, integration and biculturalism are not the correct concepts. Heritage consistency refers to the degree to which one retains their original or traditional culture, which is not addressed in the scenario provided.
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