NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions Questions
Extract:
Question 1 of 5
A nurse is completing an incident report about a medication error that she made when she accidentally administered too much insulin to a diabetic client. All of the following are components of this documentation EXCEPT:
Correct Answer: A
Rationale: When completing an incident report for a medication error, it is essential to include factual information such as the type of drug involved, the amount administered, and any adverse effects on the client. However, stating the reason for administering the wrong dose should be avoided in documentation. The focus should be on reporting what happened rather than assigning blame or admitting fault. This approach helps in ensuring a thorough and accurate account of the medication error without introducing subjective elements that could complicate the investigation or resolution process.
Therefore, the correct answer is 'The reason for administering the wrong dose.'
Choices A, B, and D are vital components of incident report documentation, providing crucial details that help in understanding the error and its impact on the client.
Question 2 of 5
Which type of shock is related to low blood volume?
Correct Answer: D
Rationale: Hemorrhagic shock, also known as hypovolemic shock, is directly related to low blood volume due to significant blood loss. In hemorrhagic shock, the body's circulating blood volume is reduced, leading to inadequate perfusion of tissues and organs. Psychogenic shock is caused by emotional distress, not blood volume changes. Cardiogenic shock results from heart failure, not low blood volume. Anaphylactic shock is due to a severe allergic reaction, not a reduction in blood volume.
Question 3 of 5
A nurse caring for a client diagnosed with pertussis is ordered to maintain droplet precautions. Which of the following actions of the nurse upholds droplet precautions?
Correct Answer: C
Rationale: When caring for a client requiring droplet precautions, it is essential for the nurse to wear a mask when within 3 feet of the client. This practice helps prevent the transmission of droplet particles that may be produced when the client coughs or sneezes. Assigning the client to a negative-pressure room is not typically necessary for droplet precautions unless specifically indicated for airborne precautions. Using sterilized equipment when sharing between clients with pertussis is important for infection control but does not directly relate to droplet precautions.
Therefore, the correct action to uphold droplet precautions in this scenario is to wear a mask when coming within close proximity to the client.
Question 4 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 5 of 5
What is the initial step to take when a patient passes out at the front desk?
Correct Answer: C
Rationale: The correct initial step when a patient passes out at the front desk is to shake the patient gently and ask if they are okay. This step aims to assess the patient's level of responsiveness. Checking for a pulse or initiating CPR should only be done if the patient does not respond to being shaken. Calling 911 can be the next step after assessing the patient's immediate condition and providing necessary assistance.