NCLEX-PN
Reduction of Risk Potential NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
Question 2 of 5
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
Correct Answer: D
Rationale: Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks involve assessment or advanced skills that require a licensed nurse.
Question 3 of 5
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?
Correct Answer: A
Rationale: Formula or breast milk. Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.
Question 4 of 5
A nurse taking a patient's history realizes the patient is complaining of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia, and hypertension. Which of the following may be occurring?
Correct Answer: B
Rationale: Myocardial infarction may be associated with SOB and muscle weakness.
Question 5 of 5
The home health nurse is using the home Safety Assessment Scale to evaluate the dangers that may exist in the home of the client who is mildly cognitively impaired. Which finding on the scale should be most concerning to the nurse?
Correct Answer: B
Rationale: Placing cloth items on a hot stove poses an immediate fire risk, which is the most concerning safety hazard for a cognitively impaired client.