NCLEX-PN
Safety and Infection Control NCLEX Questions Questions
Extract:
Question 1 of 5
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Addressing which of the following should take priority in planning care?
Correct Answer: B
Rationale: Leukopenia. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
Question 2 of 5
The most effective nursing intervention to prevent atelectasis from developing in a post-operative client is to
Correct Answer: B
Rationale: assist client to turn, deep breathe, and cough. Deep air excursion by turning, deep breathing, and coughing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.
Question 3 of 5
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
Correct Answer: B
Rationale: The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Question 4 of 5
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is
Correct Answer: D
Rationale: weekly weight. The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A one-kilogram or 2.2 pounds of weight gain is equal to approximately 1,000 ml of retained fluid. Other options are considered as part of data collection, but they are not the most accurate indicators of fluid balance.
Question 5 of 5
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
Correct Answer: C
Rationale: A cold, pale lower leg. This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral pulses should be checked immediately.