NCLEX Questions on Reduction of Risk Potential

Question 1 of 5

A client being treated for hypertension returns to the community clinic for follow up. The client says, 'I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom.' Which of these is the best nursing diagnosis?

A. Noncompliance related to medication side effectsB. Knowledge deficit related to misunderstanding of disease stateC. Defensive coping related to chronic illnessD. Altered health maintenance related to occupation

Correct Answer: A

Rationale: Noncompliance related to medication side effects. The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not because of a lack of knowledge about the disease process.

Question 2 of 5

All of the following clients are in need of an emergency assessment except:

A. a bleeding client who has an injury from falling debris.B. an unresponsive client.C. a client with an old injury.D. a pregnant woman with imminent delivery.

Correct Answer: C

Rationale: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.

Question 3 of 5

The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

A. Assign an RN to provide total care of the clientB. Assign a nursing assistant to help the client with self-care activitiesC. Delegate complete care to an unlicensed assistive personnelD. Supervise a nursing assistant for skin care

Correct Answer: D

Rationale: Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed.

Question 4 of 5

A mother that has never breast-fed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:

A. The baby will eventually take to the breast.B. I can fix up a bottle if you want to try that.C. A small amount of weight loss in the first few days is normal.D. I can get the charge nurse to come and talk to you about breast-feeding.

Correct Answer: C

Rationale: 5-10% of birth weight loss following birth is normal for the first few days of life, and this response reassures the mother while allowing further discussion about breastfeeding challenges.

Question 5 of 5

A nurse is implementing a community awareness campaign about accidental poisoning. Which of the following should she teach in the class?

A. The child should be given milk.B. The child should be given syrup of Ipecac.C. The poison control center should be contacted.D. The child should be taken to the ER.

Correct Answer: C

Rationale: The poison control center should be contacted first to provide expert guidance on managing the poisoning.

NCLEX Questions on Reduction of Risk Potential | Nurselytic

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