Reduction of Risk Potential NCLEX

Extract:

Question 1 of 5

A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?

Correct Answer: B

Rationale: The Mantoux is the most accurate test to determine the presence of TB.

Question 2 of 5

The client with a left-sided weakness is to be discharged to home, where the client has an electrical bed. In preparation for discharge, the nurse assesses the client's ability to get out of bed independently- Which client actions indicate that further instruction is needed? Select all that apply.

A. Places the bed in the lowest position B. Raises the head of the bed (HOB) C. Rolls onto the left side D. Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position E. Slides legs off the bed while pushing against the mattress to raise the body off the bed F. Once in a sitting position, sits at the edge of the bed for a few minutes before standing

Correct Answer: C,D

Rationale: C: Rolling onto the weaker left side is incorrect; the client should roll onto the stronger right side to maximize strength and stability. D: Using the weak elbow instead of the stronger elbow and hand to push off increases the risk of injury and instability.

Question 3 of 5

A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first

A. focus on reality orientation to place and person B. assist with the report of the client's complaint to the police C. obtain more details of the client's claim of abuse D. document the statement on the client's chart with a report to the manager

Correct Answer: C

Rationale: Obtain more details of the client's claim of abuse. The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse to ensure appropriate action and protection for the client.

Question 4 of 5

The nurse is teaching parents measures to prevent scald and burn injuries to toddlers in the home. Due to toddlers' inquisitiveness, which recommendation by the nurse is most important?

A. Turn pot handles toward the back of the stove. B. Use the microwave cautiously when cooking. C. Ensure that the smoke detector is on and working. D. Verify that the bathwater temperature is tepid.

Correct Answer: A

Rationale: Turning pot handles back prevents toddlers from grabbing them, addressing their curiosity and reducing scald risks.

Question 5 of 5

A nurse is reviewing a patient's ECG report. The patient exhibits a flat T wave, depressed ST segment and short QT interval. Which of the following medications can cause all of the above effects?

A. Morphine B. Atropine C. Procardia D. Digitalis

Correct Answer: D

Rationale: Digitalis can cause all of the listed ECG changes, including flat T waves, depressed ST segments, and shortened QT intervals, due to its effects on cardiac electrophysiology.

Reduction of Risk Potential NCLEX | Nurselytic

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