NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client is being assisted with ambulation in the hallway using a gait belt when they become dizzy and start to faint. What is the first action the nurse should take?
Correct Answer: A
Rationale: If a client becomes dizzy and starts to faint while being assisted with ambulation, the nurse's first action should be to assist the client into a sitting position to prevent or reduce the impact of a fall. This can be done by guiding the client to sit in the nearest chair or sliding down along a wall for support. Option A is incorrect because standing behind the client may not prevent a fall and could potentially lead to injury. Option C is incorrect as pulling the client upward may worsen the situation. Option D, calling for help, is not the first action to take when the client is at risk of falling.
Question 2 of 5
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 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
An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?
Correct Answer: D
Rationale:
To reduce the risk of falling at home for an elderly client with decreased visual acuity and using a cane for mobility, installing non-slip pads in the shower or bathtub is crucial. This measure helps prevent slips and falls in areas where water accumulation may occur. While taking off shoes and wearing socks may seem comfortable, it increases the risk of slipping. Limiting activities to the lower level of the home may restrict the client's independence and quality of life unnecessarily. Keeping a lamp near the door of every room may improve visibility but does not directly address the risk of falls associated with mobility and visual acuity issues.
Question 5 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.