NCLEX-PN
Safety and Infection Control NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse completed discharge teaching for the client with sutures in place after a skin biopsy. Which statements by the client indicate an understanding of the teaching? Select all that apply.
Correct Answer: A,C,E
Rationale: A: Clean, dry, intact incisions indicate proper care. C: Fever suggests infection, requiring follow-up. E: Redness, pain, or drainage are infection signs. B: Sutures are removed in 7-10 days. D: Incisions should be checked daily.
Question 2 of 5
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is
Correct Answer: D
Rationale: weekly weight. The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A one-kilogram or 2.2 pounds of weight gain is equal to approximately 1,000 ml of retained fluid. Other options are considered as part of data collection, but they are not the most accurate indicators of fluid balance.
Question 3 of 5
The most effective nursing intervention to prevent atelectasis from developing in a post-operative client is to
Correct Answer: B
Rationale: assist client to turn, deep breathe, and cough. Deep air excursion by turning, deep breathing, and coughing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.
Question 4 of 5
The hospitalized client has protective precautions (reverse isolation) in place because of severe neutropenia. Which statement by the nurse to the NA is correct regarding the use of protective precautions?
Correct Answer: B
Rationale: B: Minimizing time outside the room reduces pathogen exposure. A, D: Gloves and masks are not required unless infection is present. C: Positive, not negative, air pressure is needed.
Question 5 of 5
A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?
Correct Answer: C
Rationale: Improved respiratory status and increased urinary output. Digoxin, a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia, dysrhythmia, and visual and GI disturbances.