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. Intermittent fevers are:
- A. fevers which come and go.
- B. fevers which rise and fall but are always considered above the patient's average temperature.
- C. fevers which fluctuate more than three degrees and never return to normal.
- D. None of the above.
Correct answer: A
Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.
3. Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?
- A. Vest restraints should be used because they are the least restrictive type.
- B. Restraints should be used for 48 hours in non-psychiatric patients.
- C. Restraints should be applied to prevent wandering behavior.
- D. Alternative measures must be attempted first.
Correct answer: D
Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.
4. Which bloodborne pathogen is the most virulent? (Choose the BEST answer.)
- A. HCV
- B. HPV
- C. HIV
- D. HBV
Correct answer: A
Rationale: The correct answer is HCV (Hepatitis C Virus). Hepatitis C is considered the most virulent bloodborne pathogen, being 100 times more virulent than Hepatitis B. HPV (Human Papillomavirus) is a sexually transmitted infection but is not a bloodborne pathogen. HIV (Human Immunodeficiency Virus) affects the immune system but is not as virulent as Hepatitis C in terms of bloodborne transmission. HBV (Hepatitis B Virus) is less virulent compared to HCV in the context of bloodborne transmission.
5. What is the most useful patient position for proctologic exams?
- A. Trendelenburg
- B. Semi-Fowler's
- C. Full Fowler's
- D. Jack Knife
Correct answer: D
Rationale: The Jack Knife position is the most useful for proctologic exams as it allows the patient to lie face down while keeping the buttocks elevated, providing optimal access for the examination. The Trendelenburg position, characterized by the body being laid flat with the feet higher than the head, is not suitable for proctologic exams. Semi-Fowler's and Full Fowler's positions are typically utilized for respiratory or cardiovascular conditions and are not ideal for proctologic examinations due to their lack of optimal access to the perianal area.
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