NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions Questions
Extract:
Question 1 of 5
What is the minimum amount of personal protective equipment for a nurse when working with a newborn immediately after a high-risk delivery in a client's room?
Correct Answer: C
Rationale: The correct answer is gloves. When attending a high-risk delivery and handling a newborn immediately after birth, the minimum personal protective equipment required for a nurse includes gloves. This is essential to protect the nurse from potential exposure to the mother's blood or body fluids that may be present on the newborn's skin.
Choices A, B, and D include additional protective equipment that is not necessary for this specific scenario. Wearing gloves is crucial for infection control and to prevent the transmission of pathogens.
Question 2 of 5
While performing CPR, a healthcare provider encounters a client with a large amount of thick chest hair when preparing to use an automated external defibrillator (AED). What is the next appropriate action for the healthcare provider?
Correct Answer: C
Rationale: When using an AED, it is crucial for the pads to have good contact with the skin to effectively deliver an electrical shock. While AED pads can adhere to a client's chest even with some hair, thick chest hair can hinder proper current conduction. In such cases, it is recommended to shave the area of the chest where the pads will be applied. Most AED kits include a razor for this purpose. The healthcare provider should act promptly to minimize delays in defibrillation. Option A is incorrect because it may lead to ineffective treatment due to poor pad adherence. Option B is not the best course of action as wiping the chest may not resolve the issue of poor pad contact. Option D is incorrect as not using the AED could jeopardize the client's chance of survival in a cardiac emergency.
Question 3 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 4 of 5
What is the proper personal protective equipment necessary for collecting a sputum specimen?
Correct Answer: A
Rationale: When collecting a sputum specimen, it is crucial to protect against potential airborne droplets that may spread disease. The best personal protective equipment for this task includes gloves and a face mask. Gloves help prevent the spread of contaminants through hand contact, while a face mask protects the respiratory tract from inhaling infectious agents.
Choice B, Level Three Biocontainment uniforms, is excessive and unnecessary for routine sputum specimen collection.
Choice C, eye protection and shoe covers, does not address the specific risks associated with sputum collection.
Choice D, splash shield and face mask, provides additional protection that is not typically required for sputum specimen collection, making it less appropriate than gloves and a face mask.
Question 5 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.