NCLEX-PN
Next Generation Nclex Questions Overview 3.0 ATI Quizlet Questions
Extract:
Question 1 of 5
Why is padding on a restraint helpful?
Correct Answer: A
Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm.
Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm.
Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution.
Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.
Question 2 of 5
A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?
Correct Answer: C
Rationale: The correct answer is "I should lay him on his back during a seizure."? This statement indicates a need for further teaching because a client having a seizure should be turned to the side to prevent aspiration of secretions.
Choices A, B, and D are correct. Getting plenty of rest helps in managing seizures, having a medical alert bracelet informs others about the condition in case of emergency, and loosening clothing during a seizure ensures better air circulation and prevents injury. These actions demonstrate adequate understanding of the teaching provided.
Question 3 of 5
A client with which of the following conditions is at risk for developing a high ammonia level?
Correct Answer: D
Rationale: A client with cirrhosis is at risk for developing a high ammonia level due to impaired liver function. The liver normally converts ammonia into urea for excretion. In cirrhosis, this process is compromised, leading to elevated ammonia levels in the blood. Renal failure, psoriasis, and lupus do not typically cause high ammonia levels. Renal failure affects kidney function, while psoriasis and lupus are autoimmune conditions that do not directly impact ammonia metabolism.
Question 4 of 5
Which of the following statements describes the purpose of client restraint?
Correct Answer: B
Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others.
Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.
Question 5 of 5
How often should physical restraints be released?
Correct Answer: A
Rationale: The correct answer is to release physical restraints every 2 hours. Releasing restraints every 2 hours helps prevent complications associated with prolonged immobilization. Releasing restraints every 30 minutes (choice
C) may be too frequent and disruptive to the client's care. Releasing restraints between 1 and 3 hours (choice
B) introduces variability that could lead to inconsistencies in care. Releasing restraints at least every 4 hours (choice
D) does not adhere to the recommended frequency of every 2 hours.