NCLEX Reduction of Risk Potential

Extract:

Question 1 of 5

Signs of internal bleeding include all of the following except:

Correct Answer: C

Rationale: Vomiting bile is usually not a sign of internal bleeding. Painful or swollen extremities, a tender, rigid abdomen, and bruising are indicative of internal bleeding.

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?

A. "The wrist restraint must remain on at all times but can be loosened if needed." B. "The client attempted to harm staff; only enter the room with another person." C. "Ask the client about the need for toileting and offer liquids every two hours." D. "Assess the client's skin condition and provide hand exercises every two hours."

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

Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility?

A. An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits. B. A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago C. An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D. A young adult in the second day of treatment for an overdose of acetaminophen

Correct Answer: D

Rationale: A young adult in the second day of treatment for an overdose of acetaminophen. An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time. A strong risk of liver failure exists immediately following Tylenol overdose.

Question 4 of 5

The non-English-speaking hospitalized client begins to enter a room with the sign illustrated. Which intervention should the observing nurse implement?

A. Inform the client's assigned nurse that the client is back in his or her room. B. Intercept the client and check the client's name band for a room number. C. Stop the client and ask for his or her name and the assigned room number. D. Ask the nearby UAP to help the client back into the room with the sign posted.

Correct Answer: B

Rationale: Intercepting and checking the name band ensures the client does not enter a radiation therapy room, accounting for the language barrier.

Question 5 of 5

Padding on a restraint helps:

A. with pressure distribution so that bony prominences do not receive pressure when a client pulls against the restraints. B. the client feel more secure. C. to keep infection and wounds down. D. to keep restraints in place.

Correct Answer: A

Rationale: Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client pulls against the restraints. Pressure, especially over bony prominences, causes tissue damage due to ischemia.

NCLEX Reduction of Risk Potential | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN