NCLEX-PN
Safety and Infection Control NCLEX RN Questions Questions
Extract:
Question 1 of 5
A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?
Correct Answer: C
Rationale: Keep conversations short. Keeping conversations short will promote the client's comfort by decreasing demands on the client's breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, it may increase demands on the client's energy. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.
Question 2 of 5
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
Correct Answer: D
Rationale: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.
Question 3 of 5
A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse?
Correct Answer: C
Rationale: Participate with the compressions or breathing. Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse to leave the room for equipment. The client's advanced directives should have been filed on admission and his choices known prior to the initiation of CPR.
Question 4 of 5
What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
Correct Answer: B
Rationale: Oozing liquid stool. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.
Question 5 of 5
Which of these findings would the nurse more closely associate with dehydration in a 10 month-old infant?
Correct Answer: A
Rationale: Status of the eyes and the tongue. Clinical findings of dehydration include sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased pulse. The normal pulse rate in this age child is 70-110.