NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions Questions
Extract:
Question 1 of 5
When educating a client about their new prescription for warfarin, what should the nurse advise?
Correct Answer: B
Rationale: The correct answer is to advise the client to avoid any activities that could lead to injury when taking warfarin. Warfarin is an anticoagulant medication that decreases blood clotting, increasing the risk of bleeding. Engaging in activities that may result in injury can lead to uncontrolled bleeding, which can be serious. While monitoring white blood cell count is not specifically related to warfarin therapy, avoiding leafy green vegetables is important due to their vitamin K content, which can interfere with warfarin's effectiveness.
Therefore, the client should be educated to avoid activities that could cause injury to prevent potential bleeding complications.
Question 2 of 5
Your patient who had AIDS/HIV has just died. Should you still use standard precautions as you provide post-mortem care?
Correct Answer: A
Rationale: Yes, you should still use standard precautions even after an HIV/AIDS patient has died. The virus can remain infectious after death, and healthcare workers need to protect themselves from potential exposure.
Choice B is incorrect because while respect is important, the primary reason for using standard precautions is to prevent transmission of infectious diseases.
Choice C is incorrect as the virus can still be transmissible even after the patient's death.
Choice D is incorrect as using standard precautions is a matter of infection control, not a question of respect.
Question 3 of 5
The acronym FAST is used to help responders remember the steps to recognizing which of the following conditions?
Correct Answer: B
Rationale: The correct answer is B: Stroke. The acronym FAST is used to help recognize the signs of a stroke. The letters stand for Face, Arms, Speech, and Time. This mnemonic helps in identifying facial drooping, arm weakness, speech difficulties, and the importance of time in seeking emergency care.
Choices A, C, and D are incorrect because the FAST acronym specifically pertains to stroke recognition, not the onset of labor, heart attacks, or migraines.
Question 4 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 5 of 5
Surgical asepsis is being performed when:
Correct Answer: B
Rationale: Surgical asepsis refers to the process of maintaining a sterile environment to prevent the introduction of pathogens to a patient's body. Sterilizing instruments is a crucial aspect of surgical asepsis as it ensures that the instruments used during procedures are free from microorganisms that could cause infections. Wiping down exam tables with bleach may help in cleaning and disinfecting surfaces but does not pertain directly to maintaining a sterile field. Changing table paper is important for cleanliness and infection control but is not specifically related to surgical asepsis. Wearing gloves when performing injections is important for standard precautions and preventing the spread of infection but does not encompass the concept of surgical asepsis, which focuses on maintaining a sterile field during invasive procedures.