NCLEX-PN
NCLEX Reduction of Risk Potential Questions
Question 1 of 5
A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?
Correct Answer: D
Rationale: In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared.
Question 2 of 5
When entering the client's room, the nurse sees that the client is standing on the far side of the room with clothing on fire. Which action should be taken by the nurse immediately?
Correct Answer: D
Rationale: Instructing the client to drop and roll immediately smothers the flames, addressing the fire on the client's clothing most effectively.
Question 3 of 5
A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is
Correct Answer: B
Rationale: Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.
Question 4 of 5
The UAP is caring for the client who has been placed in bilateral wrist restraints. Which direction should the nurse give to the UAP?
Correct Answer: C
Rationale: The UAP should check toileting and hydration needs every two hours, as the restrained client cannot manage these independently. Skin assessment (
D) is beyond UAP scope.
Question 5 of 5
The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch selections indicates the client has learned about sodium restriction?
Correct Answer: B
Rationale: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.