NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions Questions
Extract:
Question 1 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 2 of 5
Which of the following actions is most appropriate for reducing the risk of infection during the post-operative period?
Correct Answer: C
Rationale: The most appropriate action to reduce the risk of infection during the post-operative period is to remove the urinary catheter as soon as the client is ambulatory. Urinary catheters can serve as a source of bacteria, increasing the risk of infection in the bladder or urethra. By removing the catheter promptly once the client is mobile, the risk of infection can be minimized. Option A, flushing the central line with heparin, is not directly related to reducing urinary tract infections. Option B, administering narcotic analgesics as needed, is important for pain management but does not directly address infection prevention. Option D, ordering a high-protein diet, may be beneficial for wound healing but does not specifically target infection risk reduction in the post-operative period.
Question 3 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.
Question 4 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 5 of 5
A home health nurse is preparing to visit her next client, whom she has never visited before. Which of the following actions indicates the nurse is upholding safety precautions?
Correct Answer: D
Rationale: The correct answer is to keep the car windows rolled up when in an unfamiliar environment. This action helps uphold safety precautions for the home health nurse. When visiting a new client in an unfamiliar area, it is essential to ensure personal safety. Keeping the car windows rolled up can prevent potential intruders or unwanted individuals from gaining access to the nurse while in the vehicle. This precaution is important for personal safety and security.
Choice A, sending a text to the client to confirm the location of the house, is not directly related to the nurse's safety during the visit. While communication with the client is important, it does not directly address the nurse's safety.
Choice B, leaving her purse and valuables on the seat in the car, poses a security risk. It is not advisable to leave valuables visible in the car, as it may attract thieves and compromise the nurse's safety.
Choice C, asking the client to keep an extra set of keys, is more related to accessibility and convenience rather than the nurse's safety. While having an extra set of keys may be helpful, it does not directly address safety precautions for the nurse.