NCLEX Reduction of Risk Potential

Extract:

Question 1 of 5

When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because

Correct Answer: A

Rationale: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of individuals.
To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.

Question 2 of 5

When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?

A. Competitive board games with older children B. Playing with their own toys along side with other children C. Playing alone with hand held computer games D. Playing cooperatively with other preschoolers

Correct Answer: D

Rationale: Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.

Question 3 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 4 of 5

The nurse is preparing a presentation on workplace incivility. Which incivility behaviors should the nurse plan to include in the presentation? Select all that apply.

A. Verbal intimidation of nurses and invasion of personal space by HCPs. B. Personal insults, then ignoring a person as if that person is not present. C. Discussion between the nurse and HCPs about the client's condition. D. Teasing that occurs between nurses, HCPs, or other employees. E. Reporting the behaviors using the facility's incivility report form.

Correct Answer: A,B,D

Rationale: A: Verbal intimidation and space invasion are uncivil. B: Insults and ignoring are uncivil behaviors. D: Teasing can be disrespectful and uncivil. C and E are not behaviors but actions.

Question 5 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?

A. Cheese sandwich with a glass of 2% milk B. Sliced turkey sandwich and canned pineapple C. Cheeseburger and baked potato D. Mushroom pizza and ice cream

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.

NCLEX Reduction of Risk Potential | Nurselytic

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