NCLEX Reduction of Risk Potential

Extract:

Question 1 of 5

The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch selections indicates the client has learned about sodium restriction?

Correct Answer: B

Rationale: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.

Question 2 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?

A. Wait until sufficient help is available to pull up and reposition the client in bed B. Place pillows over the bed guard and elevate both of the client's legs on the pillows C. Place the bed in Trendelenburg position to relieve the pressure and then wait for help D. Use a slight Trendelenburg position, have the client lift the heels, and pull the client up in bed

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 3 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.

Question 4 of 5

Signs of internal bleeding include all of the following except:

A. painful or swollen extremities. B. a tender, rigid abdomen. C. vomiting bile. D. bruising.

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 5 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.

NCLEX Reduction of Risk Potential | Nurselytic

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NCLEX-PN

NCLEX-PN