Reduction of Risk Potential NCLEX

Extract:

Question 1 of 5

All of the following are causes of vaginal bleeding in late pregnancy except:

Correct Answer: B

Rationale: Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizure and/or coma.

Choices 1 and 3 are abnormal conditions that can cause bleeding, particularly in the third trimester.
Choice 4 is a major obstetrical emergency that can cause bleeding internally and externally.

Question 2 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 3 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 4 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 5 of 5

A power outage occurs at a hospital, and a backup generator supplying power to a telemetry unit fails. After obtaining a flashlight, what is the nurse's next best action?

A. Call the nursing supervisor B. Assess the most critically ill clients C. Obtain oxygen tanks for clients on oxygen D. Delegate which clients the NA should monitor

Correct Answer: C

Rationale: Obtaining oxygen tanks is the priority, as room oxygen sources fail during a power outage, and clients on oxygen are at immediate risk.

Reduction of Risk Potential NCLEX | Nurselytic

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NCLEX-PN

NCLEX-PN