NCLEX-RN
Psychosocial Integrity NCLEX RN Questions Questions
Extract:
Question 1 of 5
During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?
Correct Answer: B
Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building.
Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.
Question 2 of 5
A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take?
Correct Answer: D
Rationale: Assisting the client to express feelings helps de-escalate agitation by addressing the underlying emotions, promoting safety and therapeutic communication. Seclusion is a last resort, reflection may not address acute agitation, and journaling may not be feasible in this state.
Question 3 of 5
The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?
Correct Answer: A
Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (
A). Left side-lying position (
B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (
C). Assisting the client in flexing the neck forward (
D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.
Question 4 of 5
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
Correct Answer: A
Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry.
Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.
Question 5 of 5
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
Correct Answer: D
Rationale: When a postoperative client's respiratory rate increases, it is essential to determine the underlying cause. Pain, anxiety, and fluid accumulation in the lungs can lead to tachypnea (increased respiratory rate).
Therefore, the priority intervention is to assess if pain is the contributing factor. Encouraging increased ambulation may worsen oxygen desaturation in a client with a rising respiratory rate. Offering a high-carbohydrate snack is not indicated as it can increase carbon metabolism; instead, consider providing an alternative energy source like Pulmocare liquid supplement. Forcing fluids may exacerbate respiratory congestion in a client with a compromised cardiopulmonary system, potentially leading to fluid overload.
Therefore, determining the role of pain in tachypnea is crucial for appropriate management.