In the Safe and Effective Care Environment NCLEX Category, nurse promotes achievement of client outcomes by providing and directing nursing care that enhances the care delivery setting in order to protect clients and other health care personnel. It includes two sub-categories:
- Management of Care – providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel.
- Safety and Infection Control – protecting clients and health care personnel from health and environmental hazards.
NCLEX Questions on Safe and Effective Care
1. The physician’s order reads: “100cc D5W with80 mEQ of KCL to infuse in 1/2 hour.” Your first action will be to:
a. assess urine output.
b. ensure the patency of the IV line.
c. request an order for Lidocaine to be added to the IV
d. check the accuracy of the order.
Potassium chloride must be diluted and administered at a rate no faster than 20mEq/hr. Options #1 and #2 are correct after the order has been corrected. Option #3, Lidocaine, should not be added to this IV.
2. A client diagnosed with acquired immunodefi¬ciency syndrome (AIDS) is admitted to a medical unit for treatment of dehydration secondary to diarrhea. Which nursing action is necessary to prevent nosocomial infection?
a. Provide room with an intercom.
b. Use sterile sheet whenever possible.
c. Use chux to prevent skin irritation.
d. Use a doughnut foam ring on coccyx.
Diarrhea predisposes AIDS clients to decubiti which can lead to significant infection. There¬fore, sterile sheets are indicated to reduce risk. Options #1, #3, and #4 do not decrease the risk of infection.
3. The nurse is changing a dressing on an infected abdominal wound with Penrose drains and a large amount of purulent drainage. What is the best way to perform this procedure?
a. Obtain clean gloves and dressings, remove the soiled dressing, and use another pair of clean gloves to dress the wound.
b. Use clean gloves to remove the soiled dressings, change to sterile gloves and use sterile dressings to cover the wound.
c. Use the sterile gloves to remove the dressing, obtain clean gloves and sterile dressing to reapply to the wound.
d. Initiate protective isolation, utilize only sterile gloves when removing the dressing, and reapply using sterile technique.
Sterile gloves and dressings are used in the application of dressings to wounds. Option #4 is incorrect because protective isolation is not appropriate for this client. Sterile gloves are not necessary for removing the soiled dressings.
4. A client with a history of cardiac disease is admit¬ted to the hospital with a diagnosis of congestive heart failure. The doctor’s orders are: continue all previous medications which include digoxin (Lanoxin) .25 mg po each AM, and propranolol (Inderal) 20 mg po tid; oxygen at 4L/minute via nasal cannula, establish an IV and give furosemide (Lasix) 40 mg IV now, bathroom privileges, full liquid diet. Which part of the order would be apriority for the nurse to discuss with the doctor?
a. Digoxin (Lanoxin) 0.25 mg PO in AM.
b. Level of oxygen concentration.
c. Propranolol (Inderal) 20 mg tid.
d. How fast should the IV infuse.
Inderal is contraindicated in clients with CHF. It is possible the doctor overlooked this in reordering all of the client’s previous medica¬tions. The oxygen, and digoxin are appropriate. There is no specific order regarding the rate of infusion or any fluids to be infused. Since the client is on po fluids, this is probably a heparin/saline lock. This order should be clarified. However, Option #3 is a priority.
5. Which assignment is the most appropriate for a client in the burn unit who has a cytomegalovirus (CMV) infection? A nurse who
a. has an upper respiratory infection. c. is CMV negative.
b. is eight weeks pregnant. d. has thirty years experience.
This option is most appropriate due to a decreased risk of being infected. Option #1 is incorrect because those with a cytomegalovi-rus positive titer are often immunosuppressed clients who should be protected from other pathogens. Option #2 is incorrect because CMV is fetotoxic, and those who are preg¬nant should not care for CMV+ clients. Option #3 is incorrect because those with no protective titer are an increased risk for developing the disease if exposed.
6. Which measure should a nurse take to prevent the spread of active pulmonary tuberculosis?
a. Restrict visitors to immediate family only.
b. Wear gown and gloves at all times.
c. Wear mask and gloves when in direct contact.
d. Dispose of waste articles more frequently.
Respiratory precautions call for masks and gloves to be worn to prevent the spread of the causative organism. Options #1, #2, and #4 are not essential in respiratory isolation.
7. A postoperative nursing goal is to maintain ad equate nutrition and elimination. Which nursing order would be appropriate?
a. Assess for peristalsis; do not begin PO fluids until bowel sounds are present.
b. Maintain client NPO until passing flatus; maintain normal urine output.
c. Catheterize client; place retention catheter if unable to void 4 hours after surgery.
d. Anticipate abdominal distention; place nasogastric tube PRN every 4 hours.
To prevent abdominal distention, PO fluids should not be started until bowel sounds are present or there is other evidence of active peristalsis. Option #2 is incorrect because the client does not have to be NPO until bowel sounds are established. Option #3 is incor¬rect because catheterization should be avoided unless absolutely necessary. Option #4 is incorrect because nasogastric tubes are not placed on a PRN bases.
8. A 54-year-old client with tertiary syphilis is admitted to a nursing unit exhibiting signs of marked dementia and disorientation. Which nursing action should be done initially?
a. Place the nurse call bell within reach
b. Frequently observe client behavior
c. Apply a vest-type restraint.
d. Provide an around-the-clock sitter.
Placing the client on frequent observation status would be the first action to ensure the client’s safety. Option #1 is incorrect because it should not be assumed that the client will be able to use the call light appropriately. Option #3 should never be the first option used by a professional nurse. Current stan¬dards require not only a physician’s order, but a time limit, exact type of restraint to be used, and the specific rationale for restraint. Option #4 may be suggested to the family at a later time.
9. A client with a necrotizing spider bite is to perform dressing changes at home. Which statement made by the client indicates a correct understanding of aseptic technique?
a. “I need to buy sterile gloves to redress this wound.”
b. “I should wash my hands before redressing my wound.”
c. “I should not expose the wound to air at all.”
d. “I should use an over-the-counter antimicrobial ointment.”
The hallmark of asepsis is hand-washing. Option #1 is incorrect because the question addresses medical aseptic technique, not sterile procedure. Option #3 is not necessary. Option #4 is incorrect because the client should use only prescribed medications on the wound.
10. Before administering pin site care to a client in skeletal traction, the nurse should check:
a. correct alignment
b. appearance of pin sites.
c. tightness of screws.
d. client vital signs.
Prior to pin site care, each pin site should be examined carefully for drainage or redness since they represent direct access to bone. Options #1, #3, and #4 are unnecessary with respect to site care.
11. Which observation indicates the need for a nurse to stay with a client admitted to the emergency room following a car wreck?
a. Disorientation and irregular vital signs.
b. Irregular vital signs and hostility.
c. Rapid respirations and agitation.
d. Elevated vital signs and apprehension.
A disoriented client with irregular vital signs represents a grave safety risk. Options #2, #3, and #4 may increase the need for nursing interaction/assessment and are secondary to Option #1.
12. In planning the debridment of a burn, a nurse would give priority to which action?
a. Assemble all necessary supplies and medications
b. Organize time for dressing change and provide emotional support.
c. Prepare the client and family for the pain the client will experience during and after the procedure.
d. Limit visitation prior to procedure to reduce client stress.
Prior planning for burn wound treatment should include organizing and planning for the mechanics of the procedure as well as the emotional support necessary for the client. Options #1, #3, and #4 may be appropriate but do not take priority over Option #2.
13. Prior to performing a physical assessment on a client who speaks little English, which nursing action is the most appropriate?
a. Attempt to prepare client with hand signals.
b. Show the client pictures of the physical exam process.
c. Contact an employee who speaks client’s primary language to translate.
d. Speak slowly as you explain what you are doing.
Staff who speak other languages are usually noted by nursing administration for such instances where a translator is the best option. Options #1, #2, and #4 would be less effective.
14. During the insertion of a central venous pressure monitor, the tip of the monitor device brushes the underside of the sterile field. Which nursing action is most appropriate?
a. Wipe the tip with alcohol before connecting to system
b. Notify the physician of the occurrence so an antibi¬otic can be given.
c. Back-flush catheter for several seconds before connecting
d. Obtain a new monitor device, and prepare for a second attempt.
Contamination of equipment mandates new equipment be employed. Options #1 and #3 are not adequate—the catheter is still contaminated. Option #2 may be appropriate later, but obtaining a new monitoring device is a priority.
15. Which postoperative nursing goal will assist in preventing deep vein thrombosis?
a. Decrease the flow of the venous blood.
b. Increase the coagulation of the blood.
c. Increase the flow of the venous blood.
d. Improve the oxygen capacity of the blood.
It is important to prevent venous Stasis by increasing the flow of venous return. Options # 1 and #2 will increase the risk associated with DVT. Option #4 will not affect the course of deep vein thrombosis.
16. Ipecac syrup has been given to a client after accidental ingestion of a poisonous plant. Which nursing observation is most important to report to the next shift?
a. No vomiting has occurred after dose was given.
b. An antiemetic has been ordered and given.
c. A slight increase in temperature has been noted.
d. The client will be NPO until the next day.
No response to Ipecac after the dose should be reported to next shift and the physician for further action. Options #2 and #3 are nonessential. Option #4 is not a high priority
17. A client with chronic lung disease is admitted to the acute pulmonary unit with: respiratory rate of 50; pulse of 140 and irregular; skin pale and cool to touch; client confused as to place and time. Orders are: oxygen per nasal cannula at 4L/minute, bedrest, soft diet and pulmonary function tests in the AM. What is the best sequence of nursing activities?
a. Place in semi-Fowler’s position, begin the oxygen, have someone stay with the client, then notify the doctor regarding the current status of the client.
b. Begin the oxygen, call the nursing supervisor, keep the bed flat to maintain blood pressure, and stimu¬late client to take deep breaths
c. Call the nursing supervisor, discuss with the family if the client has experienced this problem before, offer the client sips of clear liquids
d. Advise respiratory therapy of the client’s problem, place the client in semi-Fowler’s position, and begin the oxygen.
The doctor’s orders do not address the seriousness of the client’s condition. The doctor should be notified immediately. However, the client should not be left alone. Options #2, #3, and #4 do not address the seriousness of the client’s immediate needs.
18. The nurse arrives for the day shift and receives her assignments around 7:30 a.m. The assignment includes:
• a man with a diagnosis of rule-out an MI. He is on a monitor and having 4-6 premature beats per hour.
• an elderly lady who is confused and has constant urinary dribbling.
• a pneumonia client with increasing confusion and a temperature of 104° at 6:30 a.m.
• a diabetic client who experienced a restless night and 7:00 a.m. blood sugar was 170mg%.
Which client is a priority and how should the nurse plan her care?
a. The pneumonia client has priority; his condition should be assessed immediately.
b. The elderly lady is probably wet and uncomfortable and should be taken care of first. Then obtain a stat blood glucose to determine the diabetic client’s current blood sugar level.
c. The cardiac client should be assessed immediately as the monitor indicates cardiac irritability. Then the temperature on the pneumonia client should be reassessed.
d. The diabetic client should be seen immediately to assess for evidence of hyperglycemia. Then the pneumonia client should be assessed for patency of airway.
The sickest client is the pneumonia client, and his needs should be addressed first. This client has an increased temperature, which may indicate his pneumonia is getting worse; and his confusion may be indicative of hypoxia. His status should be evaluated immediately. Premature beats of 4—6 per hour are benign and not unusual for a cardiac client. The elderly lady may be uncomfortable, but the respiratory status of the pneumonia client is priority. A blood sugar of 170 mg% is abnor¬mally high and should be addressed. However, the respiratory status of the pneumonia client is the highest priority.
19. Which nursing observation is most important to report to the physician on a client with a second-degree thermal injury to right arm?
a. Pain around the periphery of injury.
b. Gastric pH less than 6.0.
c. Increased edema of right arm.
d. An elevated hematocrit.
A decrease in gastric pH could indicate the hypersecretion of hydrogen ions—a predisposing factor to stress ulcer formation. Options #1, #3, and #4 are expected findings in burn wound resolution.
20. In planning health teaching about the Recombivax immunization against Hepatitis, it is most impor¬tant to include:
a. recombivax is given at specific intervals in a series of three.
b. the immunization can only be given IM.
c. allergic reactions are possible since human plasma is used.
d. recombivax has been associated with AIDS
The necessity of completing the series of three injections is an important factor to include in education concerning immunization with Recombivax. Options #2, #3, and #4 contain false information.
21. A postoperative client is receiving bupivacaine hydrochloride (Marcaine) for pain through an epidural catheter. Which response should the nurse recognize as desirable for this pain management technique?
a. Decreased respirations.
c. Decreased restlessness.
d. Decreased blood pressure.
A decrease in physiological shortness of breath and restlessness is a desired outcome criteria of pain management. Options #1, #2, and #4 are undesired responses.
22. At 5:00 p.m., the nurse on the evening shift opens the nurses’ notes and discovers that the last entry was at 9:00 a.m. The day nurse did not complete the charting and did not sign the nurses’ notes. The best action for the evening nurse is to:
a. leave a note on the front of the chart for the day nurse to make a late entry and begin charting on the line below the last entry on the nurse’s notes.
b. leave enough space for the day nurse to complete her charting when she comes in the next morning.
c. not chart anything until the day nurse returns to complete the charting for her care delivered that morning.
d. call the day nurse and ask her about the care she gave that morning so the evening nurse can complete the chart.
The best way to handle the situation is to begin charting on the next line and have the day nurse make a late entry for the omitted information. Options #2, #3, and #4 would be illegal.
23. The most important information for a nurse to obtain about abdominal drainage from a client with postoperative abdominal abscess
d. amount of suction on system.
The character of the drainage, purulent or otherwise, is a major priority to note and report. Options #1 and #3 are lower priority. Option #4 is unnecessary.
24. A client has returned from surgery with a fine reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include:
a. the time and circumstances in which the rash was noted.
b. explanation to client and family the reason for rash.
c. notation on an allergy list and notification of the physician.
d. application of corticosteroid cream to decrease inflammation.
Any suspected reaction to drugs should be reported to the physician and noted on the list of possible allergies. Option #1 would be noted, but is not as high a priority as Option #3. Options #2 and #4 are inappropriate.
25. The nurse is changing the dressing on a client with a large abdominal wound. There are two Penrose drains in place. What is the priority information for the nurse to include when recording this procedure?
a. Condition of the surrounding tissue, time necessary to change the dressing, the type of dressing used.
b. Client’s tolerance of the procedure, time the dressing was changed, amount of wound drainage.
c. Client’s response to the dressing change, status of Penrose drains, type of drainage from Penrose drains.
d. Time dressing was changed, description of the wound, color and amount of drainage from Penrose drains.
The information in Option #4 best describes the essential information that should be charted after a dressing change for a wound of this type. Options #1, #2 and #3 contain important information. However, the informa¬tion in #4 is more important.
26. A client is admitted to the emergency room after a motor vehicle accident. He does not remember the accident. He is awake, oriented to person, but does not know what city he is in. He is confused regard¬ing the day and month. Pupils are equal in size and equally reactive to direct light reflex. He is com¬plaining of a severe headache and is becoming restless. The priority of care for this client is to:
a. continue to stimulate the client to keep.him oriented to his surroundings.
b. restrain the client to prevent him from injuring himself
c. perform bedside neuro checks every fifteen minutes.
d. administer meperidine hydrochloride (Demerol) for pain control and to decrease restlessness.
The client may be developing increased intracranial pressure and should be monitored closely. Option #4, Demerol, is not given for pain control. It will mask the signs of increased intracranial pressure. Option #2, restraining, is not necessary at this time, and pulling against restraints will increase intracranial pressure. Option #1, continued stimulation, does not provide any benefit for this client.
27. Which is an appropriate and cost-effective measure for a charge nurse to implement during a low census day shift?
a. Keep all staff because the patient census may increase.
b. Call the hospital supervisor, and let her make the decision.
c. Dismiss excess staff, but tell them to stay by the phone. They may be needed later.
d. Dismiss excess staff home, and tell them to take the day off with pay.
Excess staff may be floated to another unit that is in need of personnel. The house supervisor would have that information, thus making a cost effective decision. Options #1 and #4 are not cost effective. Option #3 violates the labor laws unless the nurse on call is being paid a wage to “stay by the phone
28. Which would be the most appropriate to assign to the LPN?
a. A client who is being discharged and needs new diabetic teaching
b. A client who is a new admission with chest pain.
c. A client who is receiving chemotherapy.
d. A client who has the diagnosis of Myasthenia Gravis.
Option #1 is incorrect because it requires initial teaching. The LPN can reinforce teaching, but it is currently not in the scope of practice to do the initial teaching. Option #2 would require initial assessment. LPNs can do ongoing assessment, but it is not in the scope of practice to complete the initial assessment. Option #3 would require IV management and specialized assessment skills so it is not a priority to Option #4.
29. While assessing the incision of a 2-day postopera¬tive client, a shiny pink open area is noted with underlying visible bowel. Which action should the nurse take first?
a. Cover gaping area with sterile gauze soaked in normal saline.
b. Reapply sterile dressing after cleaning with peroxide.
c. Pack opened area with sterile 3/4 inch gauze soaked in normal saline
d. Apply Neosporin ointment and cover with Tegaderm dressing.
Evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline followed by notification of the physician. Options #2, #3, and #4 are not correct responses to this complication.
30. Which intervention indicates the nurse has an understanding of safe medication administration for the pediatric client?
a. Validate the order with the chart after the medication has been administered.
b. Verify client identify by looking at the arm bracelet prior to administering the medication.
c. Contact the pharmacist for clarification of all the possible adverse reactions which may occur prior to giving any medication.
d. Administer the medication in the child’s formula to prevent an increase in anxiety.
It is imperative to verify the identity prior to implementing any procedure with any client. Medication errors often result from inappropriate identification. Option #1 is incorrect because it should be validated prior to administering it. Option #3 is unnecessary. Nurses must be aware of possible side effects as well as adverse reactions; however, it is not necessary to address with the pharmacist prior to every drug. Option #4 is inappropriate since the child may refuse the bottle. It should be given with a medication syringe or dropper.