NCLEX Questions, Free NCLEX RN Practice Test Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

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Question 1 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 2 of 5

A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:

Correct Answer: D

Rationale: Serum alpha fetoprotein screening detects neural tube defects, such as spina bifida.

Question 3 of 5

Four clients are admitted to a medical unit. If only one private room is available, it should be assigned to:

Correct Answer: B

Rationale: Neutropenia increases infection risk, so a private room minimizes exposure to pathogens.

Question 4 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 5 of 5

The nurse has documented a treatment on the wrong client's record. Which of the following methods of indicating the error is correct?

Correct Answer: A

Rationale: A single line through the error with 'error' written above and initialed (
A) maintains transparency while correcting the record. Correction fluid (
B) is unacceptable, multiple lines (
C) obscure the record, and margin notes (
D) are insufficient.

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