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Questions 149

NCLEX-RN

NCLEX-RN Test Bank

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Extract:


Question 1 of 5

A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

Correct Answer: A

Rationale: Calling security and preparing for sedation ensures the safety of the client, other patients, and staff during an uncontrolled rage.

Question 2 of 5

Which information should be reported to the state Board of Nursing?

Correct Answer: B

Rationale: Incorrect narcotic counts suggest potential diversion or mismanagement of controlled substances, which must be reported to the state Board of Nursing.

Question 3 of 5

When gathering evidence from a victim of rape, the nurse should place the victim's clothing in a:

Correct Answer: C

Rationale: A paper bag allows air circulation, preventing moisture that could degrade biological evidence.

Question 4 of 5

An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.

Correct Answer: A,C,D

Rationale: Alternatives (
A), reassessment every 2 hours (
C), and a written policy (
D) are required for restraints. Confused clients aren't always safer (
B), most restrictive (E) is incorrect, and an order is needed (F).

Question 5 of 5

The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?

Correct Answer: B

Rationale: An RN has the authority to initiate seclusion based on clinical judgment.

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