Reduction of Risk Potential NCLEX PN Questions

Question 1 of 5

While the nurse is administering medications to a client, the client states 'I do not want to take that medicine today.' Which of the following responses by the nurse would be best?

A. That's OK, its all right to skip your medication now and then.'B. I will have to call your doctor and report this.'C. Is there a reason why you don't want to take your medicine?'D. Do you understand the consequences of refusing your prescribed treatment?'

Correct Answer: C

Rationale: When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

Question 2 of 5

The client makes the following statements to the home health nurse. Which statement requires the nurse to intervene immediately?

A. "I can't lift pans from the back burners, but I can manage just fine by using the front burners of my stove."B. "I almost fell down the stairs, so I bought myself a pair of slippers with nonskid soles."C. "The grass near the sidewalk will be dead because my son insists on putting salt on the icy sidewalk."D. "My home is less costly to heat when I use my gas oven with the oven door open to heat just my living areas."

Correct Answer: D

Rationale: Using a gas oven for heating risks carbon monoxide poisoning, requiring immediate intervention to prevent a life-threatening situation.

Question 3 of 5

A nurse has been ordered to administer Morphine to a patient. Which of the following effects is unrelated to Morphine's effects on the patient?

A. Depressed function of the CNSB. Increased blood flowC. Decreased venous capacityD. Pain relief

Correct Answer: C

Rationale: Venous capacity increases with morphine use, not decreases, as it causes vasodilation.

Question 4 of 5

The nurse is caring for clients in a hospital setting. Which observations made by the nurse require intervention? Select all that apply.

A. The client's infusion pump is noted to have a cut in the center of the cord.B. The client's bed is in the high position after a nursing assistant left the room.C. The client's battery-operated CD player does not have an agency inspection tag.D. The client's bed exit alarm is beeping, and another nurse just left the room.E. The client's bedside table is placed in front of the chair where the client is sitting.

Correct Answer: A,B,D

Rationale: A: A cut cord poses an electrical shock risk. B: A high bed increases fall risk. D: A beeping bed exit alarm indicates a potential fall risk requiring immediate response.

Question 5 of 5

Which of the following statements describes the purpose of client restraint?

A. Restraints are a nursing measure used to maintain client control.B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.C. Restraints are a therapeutic measure designed to positively reinforce client behavior.D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Correct Answer: B

Rationale: The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician's order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider.

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