NCLEX-RN Safe and Effective Care Environment Answers and Rationale

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1.    Answer D. Because of the predilection toward outside and agricultural jobs, migrant workers, made up mostly of Hispanic people, this group is at higher risk for exposure.

2.    Answer D. The most common type of first-degree burn is sunburn underscoring the need for education regarding the use of sunscreens and avoiding exposure.

3.    Answer D.  Inhalation thermal injury is associated with significant morbidity and mortality. Manifestations might not show up until 24 hours post exposure.

4.    Answer B. An acute hyphema occurs as a result of a blunt injury to the eye and is manifested by a horizontal line of demarcation across the globe when the patient is upright. The manifestation occurs due to blood collected in the anterior chamber.

5.    Answer B. Initial care of the patient involves preventing further damage and rebleeding. Patients are kept at bed rest if possible and usually with the head of bed raised. TV watching is permitted but not reading. The use of atropine, ice, and eye shields are controversial, and a nurse would not prescribe a pharmacologic agent or thermal therapy although the nurse may administer a physician’s or a nurse practitioner’s order.

6.    Answer A. If safe to do so, the nurse should disconnect electrical devices from the power source. Smothering with a blanket is not indicated in an electrical fire and might serve to fuel the fire just as water or other liquids may incite an explosion or flames. The fire alarm should be activated promptly and would be the next action after disconnecting the electrical powered equipment.

7.    Answer D. The nurse should stand about 6 feet from the source of the fire. Getting much closer might put the nurse in danger.

8.    Answer A. Shutting off the bed’s electricity should be the initial step. The nurse should not touch the client until the bed is checked for faulty grounding. An electrician should assess the equipment. Oxygen should be discontinued until the equipment is cleared.

9.    Answer D. When the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol.

10.    Answer C. The HEADDSS (home, education, activities, drugs, driving, sex, suicide) assessment acronym applies primarily to adolescents, although it might be used in the middle-childhood and college-age categories if deemed appropriate.

11.    Answer C. Hymenoptera (bees, wasps, ants) envenomation can cause local and systemic allergic reactions including anaphylaxis, shock, and cardiac arrest. The history of being found outdoors suggest the possibility of an insect or viper bite(s).

12.    Answer D. Placing the side rail up on the side opposite the nurse will prevent the patient from falling. While raising both side rails would also prevent a fall, the nurse would place the client and herself at greater risk for injury by attempting to work over a raised side rail.

13.    Answer D. Urinary tract infections in the elderly are associated with sensorium changes that increases the risk of falls. Canial nerve eight (not five) dysfunction would indicate equilibrium changes as a positive Romberg sign and orthostatic vital signs.

14.    Answer C. Domestic violence strikes all social and educational strata and includes dating and intimate partner violence. The strongest predictor of adult domestic violence is a history of observing or being victimized in childhood.

15.    Answer B. Certain Asian groups practice the technique of coining, rubbing the skin vigorously with a coin until a red mark occurs. Cupping is treatment for arthritis practiced in some cultures. Coining may be mistaken for child abuse if cultural practice is not assessed. Chelation is a medical technique of removing iron and heavy metals from the body in poisoning.

16.    Answer C. Mongolian spots are a normal skin variation often seen in dark-skinned newborns and infants. Petechiae is a red, punctate lesion associated with capillary breakage while Koplik’s spots are associated with strep and found in the pharynx.

17.    Answer A. Asking about the significance of the amulet in a nonthreatening manner is the first step in conveying respect for the client’s religion/culture. Immediately passing judgment and instructing against the use of the necklace rejects the individuality of the client and their ethnic diversity. Asking why as the initial response does not convey acceptance and might impair communication and incite client defensiveness.

18.    Answer D. Motor vehicle accidents pose the greatest risk for death of the listed options. Burns and drownings are much less frequent in the older adult, although they can occur, and influenza is a medical illness.

19.    Answer C. Positioning of the car seat is based on body weight and age. At 20 lbs (9 kg), the infant or child 12 months or oldermay be placed in a forward-facing child seat.

20.    Answer C. Accidents (particularly motor vehicle) are the leading cause of death for all age groups from toddlerhood to adulthood. Poisoning while significant for this age group, is not as prevalent. Deaths from congenital defects occur most often in the neonatal and infancy stages. Influenza deaths, while possible, are much more uncommon in children. In assessing a patient in a critical illness or injury situation, the nurse brings her knowledge of age-specific causes of death.

21.    Answer C. Accidents are the number one cause of death for ages 1-44 with motor vehicle accidents accounting for the majority, while congenital conditions and medical illnesses claim the youngest and the oldest.

22.    Answer D. Motor vehicle accidents are the leading cause of death for all races and both sexes in the 1-44 year old age group.

23.    Answer C. To prevent thermal burns and scalding, hot water thermostats should be set at 120 or less. Adult skin can tolerate temperatures somewhat higher (that is, 140 or less). The class here involved parents of children.

24.    Answer A. Falls in the elderly are the leading cause of accidental injury and are associated with a large number of nursing home and hospital admissions. The other choices are possible causes but are much less common in the age group.

25.    Answer C. The nurse’s first response is to assess that the person is actually choking and then rapidly proceed to intervene using the Heimlich. Back blows are not indicated in adults with obstructed airways and might actually create a complete obstruction by dislodging a foreign body that was only partially blocking the airway.


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