NCLEX PN Reduction of Risk Potential Questions

Extract:

Question 1 of 5

The client with a right femoral arterial line is confused, thrashing about in bed, and picking at the tubing. The HCP prescribes wrist restraints. Based on this information, what should the nurse plan to do?

Correct Answer: B

Rationale: An ankle restraint is needed to prevent leg movement that could dislodge the femoral arterial line, which wrist restraints alone cannot address.

Question 2 of 5

The nurse is planning care for an 18 month-old child. Which action should be included in the child's care?

A. Hold and cuddle the child frequently B. Encourage the child to feed himself finger food C. Allow the child to walk independently on the nursing unit D. Engage the child in games with other children

Correct Answer: B

Rationale: Encourage the child to feed himself finger food. According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddler to assert his budding sense of control.

Question 3 of 5

The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Assigning which of these tasks to a UAP indicates the student needs further teaching about the delegation process?

A. Assist a client post cerebral vascular accident to ambulate B. Feed a 2 year-old in balanced skeletal traction C. Care for a client with discharge orders D. Collect a sputum specimen for acid fast bacillus

Correct Answer: C

Rationale: Care for a client with discharge orders. A registered nurse (RN) is the best person to do teaching or evaluation that is needed at time of discharge.

Question 4 of 5

Which of these clients is at highest risk for contracting a tuberculosis infection?

A. A nurse who is immune-suppressed from chemotherapy B. A nursing student with a negative purified protein derivative (PPD) test C. An elderly client in a nursing home who has never been tested for TB D. A health care worker who has a positive PPD test but negative chest x-ray

Correct Answer: A

Rationale: The immune-suppressed nurse undergoing chemotherapy is at the highest risk for contracting tuberculosis due to a weakened immune system, which reduces the ability to fight infections like TB.

Question 5 of 5

The experienced nurse is observing the new nurse providing care to the hospitalized cheat. Which action requires the experienced nurse to intervene to ensure client safety?

A. Turns on the client's bathroom light and turns out the room lights after settling the client for sleep B. Checks the client's room number and name on the name band to verify client identity prior to giving a medication C. Stirs thickening powder into the glass of juice and cup of milk before giving these to the client who has dysphagia D. Delays the HCP from performing a thoracentesis by calling "a timeout" to verify the client's identity, consent, procedure, and site

Correct Answer: B

Rationale: Room number is not a unique client identifier. The nurse should use two unique identifiers, such as the client's name and medical record number, to verify identity before medication administration.

NCLEX PN Reduction of Risk Potential Questions | Nurselytic

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