Reduction of Risk Potential NCLEX

Extract:

Question 1 of 5

The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it?

Correct Answer: A

Rationale: Hepatitis A does not produce a carrier state. It is transmitted via contaminated water or food via the oral-fecal route and is not blood borne.

Question 2 of 5

An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?

A. How long have you been a UAP and what units you have worked on? B. What type of care do you give on the surgical unit and what ages of clients? C. What is your comfort level in caring for children and at what ages? D. Have you reviewed the list of expected skills you might need on this unit?

Correct Answer: D

Rationale: The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this.

Question 3 of 5

The client with a left-sided weakness is to be discharged to home, where the client has an electrical bed. In preparation for discharge, the nurse assesses the client's ability to get out of bed independently- Which client actions indicate that further instruction is needed? Select all that apply.

A. Places the bed in the lowest position B. Raises the head of the bed (HOB) C. Rolls onto the left side D. Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position E. Slides legs off the bed while pushing against the mattress to raise the body off the bed F. Once in a sitting position, sits at the edge of the bed for a few minutes before standing

Correct Answer: C,D

Rationale: C: Rolling onto the weaker left side is incorrect; the client should roll onto the stronger right side to maximize strength and stability. D: Using the weak elbow instead of the stronger elbow and hand to push off increases the risk of injury and instability.

Question 4 of 5

The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it?

A. hepatitis A B. hepatitis B C. hepatitis C D. hepatitis D

Correct Answer: A

Rationale: Hepatitis A does not produce a carrier state. It is transmitted via contaminated water or food via the oral-fecal route and is not blood borne.

Question 5 of 5

After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

A. abdominal x-ray B. auscultation C. flushing tube with saline D. aspiration for gastric contents

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.

Reduction of Risk Potential NCLEX | Nurselytic

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NCLEX-PN

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