NCLEX-PN
Psychosocial Integrity NCLEX Questions
Extract:
Question 1 of 5
How often must physical restraints be released?
Correct Answer: A
Rationale: Restraints must be released every 2 hours to assess circulation, skin integrity, and client comfort, with assessments every 30 minutes while restrained.
Question 2 of 5
The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?
Correct Answer: D
Rationale: Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.
Question 3 of 5
How often must physical restraints be released?
Correct Answer: A
Rationale: Restraints must be released every 2 hours to assess circulation, skin integrity, and client comfort, with assessments every 30 minutes while restrained.
Question 4 of 5
A 27 year-old woman has delivered twins in the OB unit. The patient develops a condition of 5 centimeter diastasis recti abdominis. Which of the following statements is the most accurate when instructing the patient?
Correct Answer: C
Rationale: Protection of the abdominal wall is critical at this point in time.
Question 5 of 5
When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?
Correct Answer: A
Rationale: An oropharyngeal airway is measured from the corner of the client's mouth, to the tragus of the ear.