NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions Questions
Question 1 of 5
When providing endotracheal suctioning, for how long should the nurse suction the endotracheal tube of an intubated client on a ventilator at a time?
Correct Answer: B
Rationale: When providing endotracheal suctioning, the nurse should suction for no longer than ten seconds at a time. Suctioning for longer than ten seconds may cause hypoxia or bronchospasm. Extended suctioning may also place the client at risk of injury to the bronchial and tracheal structures.
Choices C and D suggest prolonged suctioning durations that can lead to adverse effects on the client.
Choice A, suctioning for five seconds or less, may not be adequate to clear secretions effectively, making choice B the most appropriate duration for safe and efficient suctioning in this scenario.
Question 2 of 5
What is the first aid for frostbite?
Correct Answer: A
Rationale: First aid for frostbite involves running cold water over the affected area. It is important to avoid warm or hot water as it can shock the area and cause further tissue damage. Warm water should not be used to rapidly rewarm the affected area. Similarly, hot water should also be avoided as it can warm the area too quickly and potentially cause harm. Covering the area with a blanket and using a heating pad may not be effective and can even lead to more damage. Seeking medical assistance is crucial if the tissue appears necrotic to prevent further complications.
Question 3 of 5
A client in a long-term care facility has developed reddened skin over the sacrum, which has cracked and started to blister. The nurse confirms that the client has not been assisted with turning while in bed. Which stage of pressure ulcer is this client exhibiting?
Correct Answer: B
Rationale: The client is exhibiting a stage II pressure ulcer. A stage II pressure ulcer develops as a partial thickness wound that affects both the epidermis and the dermal layers of skin. This stage can present with red skin, blisters, or cracking, appearing shallow and moist. However, the ulcer does not extend to the underlying tissues at this stage.
Choice A (Stage I) is incorrect as Stage I ulcers involve non-blanchable redness of intact skin.
Choices C (Stage III) and D (Stage IV) are incorrect as they involve more severe tissue damage, extending into deeper layers of the skin and underlying tissues, which is not the case in this scenario.
Question 4 of 5
A client is suspected of having carbon monoxide poisoning. Which of the following symptoms are associated with this condition?
Correct Answer: B
Rationale: The correct answer is 'Nausea, vomiting, seizures.' Carbon monoxide poisoning can present with symptoms such as headache, dizziness, weakness, nausea, vomiting, and confusion. Severe cases can progress to seizures, coma, and even death. It is crucial for healthcare providers to recognize these symptoms promptly to initiate appropriate treatment.
Choices A, C, and D are incorrect because a red rash, flushing of the face and neck, and abdominal pain radiating to the back are not typically associated with carbon monoxide poisoning. It is essential to be aware of the common manifestations of carbon monoxide poisoning to ensure timely intervention and prevent adverse outcomes.
Question 5 of 5
What is the primary route of transmission of MRSA?
Correct Answer: B
Rationale: The correct answer is 'Hands of healthcare workers.' MRSA is primarily transmitted via the unwashed hands of healthcare workers who can carry the Staphylococcus aureus bacterium from one patient to another. Shared needles, items in the healthcare environment, and blood transfusions are not the main routes of transmission for MRSA. Shared needles can transmit bloodborne pathogens, items in the healthcare environment can harbor bacteria but are not the primary mode for MRSA, and blood transfusions are not a common route for MRSA transmission.