NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. Should standard precautions be used when providing post mortem care to a patient who has died from a massive heart attack and had no other diseases, illnesses, or infections?
- A. Yes, because the patient must be treated with respect
- B. Yes, you still must use standard precautions
- C. No, because the patient had no infections
- D. No, because this is not respectful
Correct answer: B
Rationale: Yes, you must still use standard precautions when providing post mortem care, regardless of the patient's medical history. Standard precautions are essential to prevent the transmission of potential infectious agents and protect both the healthcare provider and others from exposure. Even if the patient did not have known infections, it is crucial to maintain a safe environment and uphold professional standards of care. Choice A is incorrect as using standard precautions is primarily for infection control rather than solely for respect. Choices C and D are incorrect as the absence of infections or the notion of respect does not negate the need for standard precautions in post mortem care.
2. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
- A. Listen to a patient's lung sounds for wheezes or rhonchi.
- B. Label specimens obtained during percutaneous lung biopsy.
- C. Instruct a patient about how to use home spirometry testing.
- D. Measure induration at the site of a patient's intradermal skin test.
Correct answer: B
Rationale: Labeling specimens obtained during a percutaneous lung biopsy is a task that can be appropriately delegated to unlicensed assistive personnel (UAP) as it does not require nursing judgment. UAP can perform this task safely under the supervision of a nurse. Listening to a patient's lung sounds for wheezes or rhonchi, instructing a patient about how to use home spirometry testing, and measuring induration at the site of a patient's intradermal skin test all require nursing judgment and interpretation of findings. These tasks should be performed by licensed nursing personnel to ensure accurate assessment and appropriate intervention.
3. 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.
4. Which of the following is an example of client handling equipment?
- A. Wheelchair
- B. Height-adjustable bed
- C. Shower chair
- D. Call light
Correct answer: B
Rationale: Client handling equipment is designed to reduce stress and workload on healthcare professionals who assist, turn, or lift clients, aiming to decrease the risk of injuries from improper lifting techniques. A height-adjustable bed is a prime example of client handling equipment as it allows healthcare providers to raise the client to a suitable working height, facilitating care provision. Choices A, C, and D are not examples of client handling equipment. While a wheelchair, shower chair, and call light are essential in client care settings, they are not intended to aid in handling and lifting clients.
5. For a patient who is blood type AB, which blood product can they receive?
- A. Plasma from a type B donor
- B. Whole blood from a type A donor
- C. Packed RBCs from a type O donor
- D. All of the above
Correct answer: C
Rationale: A patient with blood type AB has AB antigens on their red blood cells. This means they can only receive blood products that are compatible with these antigens. Choice A is incorrect because an AB patient cannot receive plasma from a type B donor due to the antibodies present in type B plasma. Choice B is incorrect because an AB patient cannot receive whole blood from a type A donor as it contains incompatible antigens. Choice C is the correct answer because an AB patient can receive packed RBCs from a type O donor. Type O donors have no A or B antigens, making their blood compatible for transfusion to recipients with any blood type. Therefore, choices A and B are incorrect, and the correct choice is C.
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