NCLEX-PN
NCLEX Reduction of Risk Potential Questions
Extract:
Question 1 of 5
Pressure is being exerted to the client's foot ulcer from the bottom bed guard, and the client needs to be pulled up in bed. The client weighs 130 lb. Which action by the nurse is best when no one is available to assist the nurse?
Correct Answer: D
Rationale: Using a slight Trendelenburg position leverages gravity to assist in moving a lightweight client safely, while lifting the heels prevents friction injury. Waiting for help (
A) delays relief, pillows (
B) risk sliding, and full Trendelenburg (
C) may compromise respiration.
Question 2 of 5
The UAP is caring for the client who has been placed in bilateral wrist restraints. Which direction should the nurse give to the UAP?
Correct Answer: C
Rationale: The UAP should check toileting and hydration needs every two hours, as the restrained client cannot manage these independently. Skin assessment (
D) is beyond UAP scope.
Question 3 of 5
When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
Correct Answer: B
Rationale: Deep breathing. Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.
Question 4 of 5
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because
Correct Answer: A
Rationale: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of individuals.
To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.
Question 5 of 5
A nurse working in a pediatric clinic observes bruises on the body of a four year-old boy. The parents report the boy fell riding his bike. The bruises are located on his posterior chest wall and gluteal region. The nurse should:
Correct Answer: C
Rationale: The patient's safety should have the highest priority.