NCLEX-PN
Safety and Infection Control NCLEX RN Questions Questions
Extract:
Question 1 of 5
Which of these findings would the nurse more closely associate with dehydration in a 10 month-old infant?
Correct Answer: A
Rationale: Status of the eyes and the tongue. Clinical findings of dehydration include sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased pulse. The normal pulse rate in this age child is 70-110.
Question 2 of 5
The nurse is using contact precautions when caring for the client. When changing the client's IV solution bag, the nurse inadvertently touches the end of the exposed spike of the tubing. Which is the most appropriate action by the nurse?
Correct Answer: C
Rationale: C: The contaminated spike requires new sterile tubing to prevent infection. A: Using contaminated tubing risks infection. B: Changing gloves doesn't address tubing contamination. D: Alcohol cannot sterilize the spike.
Question 3 of 5
A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?
Correct Answer: C
Rationale: Keep conversations short. Keeping conversations short will promote the client's comfort by decreasing demands on the client's breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, it may increase demands on the client's energy. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.
Question 4 of 5
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
Correct Answer: D
Rationale: Serum potassium 6 mEq/L. Although all of these findings are abnormal, the elevated potassium level is a life-threatening finding and must be reported immediately.
Question 5 of 5
A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
Correct Answer: C
Rationale: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient cardiac pumping.