NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions Questions
Question 1 of 4
Patients exhibiting signs of cyanosis will:
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.
Question 2 of 4
When would chest thrusts be performed in an emergency situation?
Correct Answer: C
Rationale: In the scenario of an emergency where a pregnant woman is choking, chest thrusts are performed to clear the airway obstruction. This technique is used instead of abdominal thrusts to avoid potential harm to the fetus. While chest thrusts are not as effective as abdominal thrusts in clearing obstructions, they are the preferred method in this specific situation. Choices A and B are incorrect as chest thrusts are not typically performed during CPR to initiate cardiovascular circulation or when assessing responsiveness of an unconscious patient. Choice D is incorrect as chest thrusts are indeed warranted when assisting a pregnant woman who is choking.
Question 3 of 4
Madge is a 91-year-old nursing home resident with a history of dementia and atrial fibrillation who has been admitted to the hospital for treatment of pneumonia. As you are performing her bed bath, you note bruising around her breasts and genital area. What potential issue should be of major concern in Madge's situation?
Correct Answer: C
Rationale: Bruising around the breasts and genitals should trigger concern for sexual abuse. Elder abuse is a growing problem in America, and nurses are uniquely positioned to recognize and intervene on behalf of vulnerable populations, such as the elderly. According to the National Center on Elder Abuse (NCEA), major types of elder abuse include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation, and self-neglect. In this scenario, given Madge's age, history of dementia, and the presence of unexplained bruising in sensitive areas, sexual abuse must be considered as a major concern. Idiopathic thrombocytopenic purpura (ITP) is a platelet disorder that presents with excessive bruising and bleeding, but it is less likely in this case as the bruising pattern is suggestive of a different cause. Embolic stroke is a neurological condition that typically presents with sudden onset neurological deficits and is not related to the observed bruising. Nursing home-acquired pneumonia (NHAP) is a common issue in elderly residents but would not manifest as bruising in specific areas like the breasts and genitals.
Question 4 of 4
During the general survey, what action is a component of the assessment?
Correct Answer: A
Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.