NCLEX Reduction of Risk Potential

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?

A. I am sorry. Referral information can only be provided by the client's providersB. I can never give any information out by telephone. How do I know who you are?C. Since this is a referral, I can give you this informationD. I need to get the client's written consent before I release any information to you

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

The UAP is caring for the client who has been placed in bilateral wrist restraints. Which direction should the nurse give to the UAP?

A. "The wrist restraint must remain on at all times but can be loosened if needed."B. "The client attempted to harm staff; only enter the room with another person."C. "Ask the client about the need for toileting and offer liquids every two hours."D. "Assess the client's skin condition and provide hand exercises every two hours."

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 3 of 5

When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?

A. Competitive board games with older childrenB. Playing with their own toys along side with other childrenC. Playing alone with hand held computer gamesD. Playing cooperatively with other preschoolers

Correct Answer: D

Rationale: Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.

Question 4 of 5

Which of these instructions should the nurse include when preparing a client for a radioactive iodine (I-131) uptake test and treatment for hyperthyroidism?

A. Avoid taking aspirin for 3 days prior to the test.'B. You may eat a light breakfast on the morning of the test.'C. Expect to stay in the hospital for 24 hours after treatment.'D. In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation.'

Correct Answer: A

Rationale: In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation. The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours.

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?

A. Cheese sandwich with a glass of 2% milkB. Sliced turkey sandwich and canned pineappleC. Cheeseburger and baked potatoD. Mushroom pizza and ice cream

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.

NCLEX Reduction of Risk Potential | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN