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. Patients exhibiting signs of cyanosis will:
- A. show signs of hyperoxia.
- B. have increased O2 saturation.
- C. have blood levels of CO2 higher than O2 levels.
- D. None of the above.
Correct answer: C
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from low blood oxygen levels. When a patient exhibits cyanosis, it indicates that their blood is poorly oxygenated, leading to a higher concentration of CO2 compared to oxygen. Options A and B are incorrect as cyanosis is associated with low oxygen levels, not hyperoxia or increased O2 saturation. Therefore, the correct answer is that patients exhibiting cyanosis will have blood levels of CO2 higher than O2 levels.
3. How does the procedure for taking a pulse rate on an infant differ from an adult?
- A. Pulse rates are taken on infants using a different method.
- B. The apical pulse method is used on infants.
- C. Pulse rates on infants are taken with a sphygmomanometer.
- D. Pulse rates on infants are taken apically in the third intercostal space.
Correct answer: B
Rationale: The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately. Choices A, C, and D are incorrect. Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method. Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates. Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.
4. The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?
- A. "Measuring temperature using the TMT is cost-effective."?
- B. "The rapid measurement of the TMT is beneficial for uncooperative younger children."?
- C. "TMT is not recommended for measuring core body temperature in newborn infants."?
- D. "TMT is not the preferred method for measuring body temperature in patients with otitis media."?
Correct answer: B
Rationale: The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.
5. A healthcare professional is preparing to administer a dose of platelets to a client. Which of the following actions must the healthcare professional perform before giving the platelets?
- A. Start an IV of 0.9% Normal Saline to administer with the platelets
- B. Ensure the container with the platelets is intact and not damaged
- C. Verify the client's identity using two unique identifiers
- D. Check the client's chart to ensure no contraindications to platelet transfusion
Correct answer: B
Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.
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