Reduction of Risk Potential NCLEX PN Questions

Extract:

Question 1 of 5

Which of the following microorganisms are considered normal body flora?

Correct Answer: A

Rationale: Of the choices given, only staphylococcus is considered a normal resident of the body.

Question 2 of 5

Which of the following statements describes the purpose of client restraint?

A. Restraints are a nursing measure used to maintain client control. B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger. C. Restraints are a therapeutic measure designed to positively reinforce client behavior. D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Correct Answer: B

Rationale: The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician's order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider.

Question 3 of 5

A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that

A. such fantasies can gratify unconscious wishes or prepare for anticipated future events B. detaching or dissociating in this way postpones painful feelings C. converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership D. isolating the feelings in this way reduces conflict within the client and with others

Correct Answer: A

Rationale: such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.

Question 4 of 5

The client makes the following statements to the home health nurse. Which statement requires the nurse to intervene immediately?

A. "I can't lift pans from the back burners, but I can manage just fine by using the front burners of my stove." B. "I almost fell down the stairs, so I bought myself a pair of slippers with nonskid soles." C. "The grass near the sidewalk will be dead because my son insists on putting salt on the icy sidewalk." D. "My home is less costly to heat when I use my gas oven with the oven door open to heat just my living areas."

Correct Answer: D

Rationale: Using a gas oven for heating risks carbon monoxide poisoning, requiring immediate intervention to prevent a life-threatening situation.

Question 5 of 5

The nurse is reinforcing teaching to a client about preventing transmission of the hepatitis A virus. Which of these instructions is most appropriate?

A. Get the hepatitis A vaccine before traveling to endemic areas.' B. Avoid sexual contact until the infection is resolved.' C. Take antiviral medications as prescribed.' D. Use condoms to prevent transmission.'

Correct Answer: A

Rationale: Hepatitis A is primarily transmitted through the fecal-oral route. Vaccination is the most effective way to prevent infection, especially before travel to endemic areas.

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