Reduction of Risk Potential NCLEX

Extract:

Question 1 of 5

After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

Correct Answer: A

Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.

Question 2 of 5

The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?

A. Focus on the child's needs and recovery B. Explain the cause of the child's illness C. Acknowledge that early care would have been better D. Accept their feelings without judgment

Correct Answer: D

Rationale: Accept their feelings without judgment. Parents often blame themselves for their child's illness. Feeling helpless and angry is normal and these feelings must be accepted.

Question 3 of 5

The nurse is teaching the client with a latex allergy about home and personal safety. Which information should the nurse emphasize? Select all that apply.

A. Remove items in the home made from synthetic materials. B. Keep emergency telephone numbers readily accessible. C. Have someone remove any latex balloons and rubber bands. D. Avoid foods such as kiwi, bananas, avocados, and chestnuts. E. Certain plants, such as poinsettia plants, help remove allergens.

Correct Answer: B,C,D

Rationale: B: Emergency numbers are critical for anaphylaxis. C: Latex items like balloons and rubber bands must be removed to avoid exposure. D: Certain foods can trigger cross-reactive allergic reactions. A and E are incorrect as synthetic materials are safe, and poinsettias can cause reactions.

Question 4 of 5

The nurse asks the NA to apply a mitten restraint for the client seated in the wheelchair next to the bed. Which observation by the nurse indicates that the NA needs further instructions on applying restraints?

A. Restraint strap is tied to the bed frame next to the client. B. Restraint straps are secured using a half-bow slip knot. C. Two fingers can be inserted between the restraint and client's skin. D. Mesh portion of the mitten restraint is on the back of the hand.

Correct Answer: A

Rationale: Tying the restraint to the bed frame instead of the wheelchair frame risks injury if the wheelchair moves, indicating the NA needs further instruction.

Question 5 of 5

An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?

A. How long have you been a UAP and what units you have worked on? B. What type of care do you give on the surgical unit and what ages of clients? C. What is your comfort level in caring for children and at what ages? D. Have you reviewed the list of expected skills you might need on this unit?

Correct Answer: D

Rationale: The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.

Reduction of Risk Potential NCLEX | Nurselytic

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NCLEX-PN

NCLEX-PN