Reduction of Risk Potential NCLEX PN Questions

Question 1 of 5

The hospitalized client states, "I can't wait for anyone to take me to the bathroom, or I will wet my pants." What should the nurse do? Select all that apply.

A. Assess the client's risk for a fall using a rating scale.B. Document that the client is frequently incontinent.C. Ensure an immediate response to the client's call light.D. Educate the client regarding fall prevention strategies.E. Place a note on the door stating, "bathroom every two hours."F. Request that the HCP prescribe placement of a urinary catheter.

Correct Answer: A,C,D

Rationale: A: Assessing fall risk is essential due to urgency. C: Prompt response to call light prevents rushing. D: Education on fall prevention is proactive. B is incorrect as incontinence cannot be assumed. E violates privacy. F is unnecessary and risky.

Question 2 of 5

A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?

A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves shaving her legs.'B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'

Correct Answer: C

Rationale: Patient confidentiality should be observed, especially in public places. The nurse should tell the nursing student do not discuss confidential information in public.

Question 3 of 5

A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that

A. a referral is needed to the psychiatrist who is to provide the client with answersB. the client has a right to know about the prescribed medicationsC. such education is an independent decision of the individual nurse whether or not to teach clients about their medicationsD. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

Correct Answer: B

Rationale: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.

Question 4 of 5

The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?

A. Encourage oral fluids to prevent dehydrationB. Recheck temperature 15 minutes after removing hot liquids from the bedsideC. Ask the client to drink only cold water and juicesD. Chart this temperature elevation on the flow sheet

Correct Answer: B

Rationale: Recheck temperature to eliminate possible artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading.

Question 5 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.

Reduction of Risk Potential NCLEX PN Questions | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN