NCLEX-PN
Reduction of Risk Potential NCLEX Questions
Extract:
Question 1 of 5
The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client
Correct Answer: C
Rationale: A change in level of consciousness indicates delirium related to acute illness. This would require the assessment of a nurse. The other changes could occur within the range of normal fluctuations.
Question 2 of 5
A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first
Correct Answer: C
Rationale: Obtain more details of the client's claim of abuse. The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse to ensure appropriate action and protection for the client.
Question 3 of 5
The nurse asks the NA to apply a mitten restraint for the client seated in the wheelchair next to the bed. Which observation by the nurse indicates that the NA needs further instructions on applying restraints?
Correct Answer: A
Rationale: Tying the restraint to the bed frame instead of the wheelchair frame risks injury if the wheelchair moves, indicating the NA needs further instruction.
Question 4 of 5
The nurse is caring for a client with a newly applied long leg cast. Which of these actions should the nurse take first to prevent complications from the cast?
Correct Answer: A
Rationale: Checking pedal pulses bilaterally is the first action to ensure adequate circulation and detect potential complications like compartment syndrome early.
Question 5 of 5
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.