Reduction of Risk Potential NCLEX PN Questions

Extract:

Question 1 of 5

The client makes the following statements to the home health nurse. Which statement requires the nurse to intervene immediately?

Correct Answer: D

Rationale: Using a gas oven for heating risks carbon monoxide poisoning, requiring immediate intervention to prevent a life-threatening situation.

Question 2 of 5

The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?

A. Encourage oral fluids to prevent dehydration B. Recheck temperature 15 minutes after removing hot liquids from the bedside C. Ask the client to drink only cold water and juices D. Chart this temperature elevation on the flow sheet

Correct Answer: B

Rationale: Recheck temperature to eliminate possible artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading.

Question 3 of 5

Which of the following statements describes the purpose of client restraint?

A. Restraints are a nursing measure used to maintain client control. B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger. C. Restraints are a therapeutic measure designed to positively reinforce client behavior. D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Correct Answer: B

Rationale: The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician's order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider.

Question 4 of 5

While the nurse is administering medications to a client, the client states 'I do not want to take that medicine today.' Which of the following responses by the nurse would be best?

A. That's OK, its all right to skip your medication now and then.' B. I will have to call your doctor and report this.' C. Is there a reason why you don't want to take your medicine?' D. Do you understand the consequences of refusing your prescribed treatment?'

Correct Answer: C

Rationale: When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

Question 5 of 5

The hospitalized client states, "I can't wait for anyone to take me to the bathroom, or I will wet my pants." What should the nurse do? Select all that apply.

A. Assess the client's risk for a fall using a rating scale. B. Document that the client is frequently incontinent. C. Ensure an immediate response to the client's call light. D. Educate the client regarding fall prevention strategies. E. Place a note on the door stating, "bathroom every two hours." F. Request that the HCP prescribe placement of a urinary catheter.

Correct Answer: A,C,D

Rationale: A: Assessing fall risk is essential due to urgency. C: Prompt response to call light prevents rushing. D: Education on fall prevention is proactive. B is incorrect as incontinence cannot be assumed. E violates privacy. F is unnecessary and risky.

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