NCLEX-PN
NCLEX PN Safety and Infection Control Questions Questions
Question 1 of 5
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
Question 2 of 5
When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
Correct Answer: B
Rationale: continuously. Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula.
Question 3 of 5
A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol?
Correct Answer: D
Rationale: Bed in lowest position, wheels locked, place bed against wall. Using all 4 side rails is considered a restraint and limits client autonomy unless medically necessary with an order. Lower side rails alone do not adequately prevent falls. The bed in the lowest position with wheels locked and placed against the wall minimizes fall risk while allowing the client freedom of movement.
Question 4 of 5
The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to
Correct Answer: D
Rationale: prevent the drug from causing tissue irritation. Deep injection or Z-track is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. Use of Z-track does not affect dose, absorption, or distribution of the drug.
Question 5 of 5
A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
Correct Answer: D
Rationale: No bowel movement for 3 days. With opioid analgesics, observe for respiratory depression, sedation, and constipation. Bruising is not related to the analgesic, but could be the result of corticosteroids or previously used anticoagulants. Elevated heart rate could be the result of bronchodilators. Some antibiotics can lower platelet count.