NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions Questions
Extract:
Question 1 of 5
Mr. and Mrs. K have just adopted a newborn infant and are preparing to take him home from the hospital for the first time. Which safety measure is most appropriate for the clients in this situation?
Correct Answer: D
Rationale: Parents of newborn infants should use an approved car seat that has been installed facing backward in the back seat of the car. Securing infants in car seats, even from the first ride home from the hospital, promotes safety while transporting. While safety measures at home such as baby gates or outlet covers are important, they are not the priority safety measures until the baby is old enough to be mobile. The car seat is crucial for protecting the newborn during transportation, ensuring proper positioning and restraint in the event of sudden stops or accidents. Turning handles of pans on the stove inward, setting up a baby gate, and covering electrical outlets are important safety measures at home but are not as critical for the immediate safety of a newborn during transportation.
Question 2 of 5
A nurse is preparing to change a client's dressing for a burn wound on his foot. Which of the following interventions is appropriate for this process?
Correct Answer: A
Rationale: When changing the dressing for a burn wound, it is essential to follow appropriate interventions to prevent infection, reduce pain, and support healing. In this scenario, after removing the old dressing, it is crucial to wash the wound gently with a suitable cleanser, rinse the area thoroughly, and then pat it dry. This process helps in maintaining cleanliness, reducing the risk of infection, and providing a conducive environment for healing. Binding the wound tightly (
Choice
B) can impede circulation and delay healing. Contacting the physician after the dressing change (
Choice
C) may be necessary in specific situations but is not a standard step in routine dressing changes. Providing analgesics after the procedure (
Choice
D) is important for pain management but is not directly related to the dressing change itself.
Question 3 of 5
A physician has ordered that a client must be placed in a high Fowler's position. How does the nurse position this client?
Correct Answer: D
Rationale: A high Fowler's position is a modification of the semi-Fowler's position, in which the client is seated with arms resting at the sides or in the lap. The high Fowler's position requires that the client's head and upper chest are elevated, and the backrest is at a 90-degree angle. This position supports breathing and appropriate chest wall movement, making it easier for the client to breathe.
Choices A, B, and C are incorrect because a high Fowler's position involves the client being in a sitting position with the backrest at a 90-degree angle, not being face-down, lying with the head lower than the feet, or lying on the back with knees drawn up towards the chest.
Question 4 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 5 of 5
Which of the following situations indicates the need to file an incident report?
Correct Answer: D
Rationale: An incident report is necessary for documenting unexpected events that occur in a healthcare setting. Situations that warrant filing an incident report include client accidents, medication errors, security problems, or disruptive behaviors that involve clients, families, or visitors. In this scenario, when a client's spouse displays disruptive behavior and is asked to leave the premises, it is essential to document this incident to ensure a record of the event and its resolution.
Choices A, B, and C do not involve disruptive behavior or safety concerns that would require an incident report to be filed.