NCLEX-PN
Safety and Infection Control NCLEX Questions
Extract:
Question 1 of 5
A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be to
Correct Answer: B
Rationale: assess for dyspnea or stridor. Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.
Question 2 of 5
A client has a chest tube inserted following a left lower lobectomy required by a stab wound to the chest. While repositioning the client, the nurse notices dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
Correct Answer: D
Rationale: It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.
Question 3 of 5
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?
Correct Answer: C
Rationale: Dyspnea. Clients having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
Question 4 of 5
A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that
Correct Answer: A
Rationale: such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.
Question 5 of 5
The nurse is using chlorhexidine to cleanse a vein site prior to inserting an IV catheter. While pressing the activated applicator on the skin, what should the nurse do next?
Correct Answer: A
Rationale: A: Back-and-forth scrubbing for 30 seconds ensures effective antisepsis. B: Circular motion and 10 seconds are inadequate. C: Visual wetness is insufficient. D: Chlorhexidine is clear, causing no discoloration.