Saunders NCLEX SAFETY

The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment? Select all that apply.

"I will remove the ice pack if I start to feel numbness." "I should wrap the frozen ice pack in a towel to help adjust to the cold."

The nurse is caring for a child following a cleft palate repair who has elbow restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention should receive highest priority regarding the restraints?

Checking color, sensation, and pulses distal to the restraints

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply.

Explain the procedure to the client. Irrigate the NG tube with saline. Elevate the head of the bed to 45 degrees.

The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled? Select all that apply.

Handgrips are positioned so the elbows are bent approximately 30 degrees. The space between the axilla and the top of the crutch pad is 1½ to 2 inches. The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.

The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply.

Homeopathy Herbal supplements

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home.

Which client is the safest one for a licensed practical nurse (LPN) to care for?

A client recovering from a scheduled cesarean delivery

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

A pair of scissors

The nurse is monitoring the laboratory results of a female client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 40,000 mm3 (40 × 109/L)

During a fire drill, the nurse enters a laundry room and a waste basket is marked as on "fire." The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher and returns to the laundry room. Which action by the nurse shows that additional training is needed?

Aiming at the top flames of the fire

The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions should the nurse take initially? Select all that apply.

Ask the client about needing to void or move bowels. Turn on the nightlight in the hospital room and bathroom. Turn on bed alarm

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should perform which actions when performing this procedure? Select all that apply.

Moistening the catheter tip in sterile saline solution before suctioning Introducing the catheter into the tracheostomy tube using a sterile gloved hand Preoxygenating the client before suctioning

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive?

Place two fingers under the restraint to determine snugness.

The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

Places the client in an upright position

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply.

Prevent debris from entering the stoma. Avoid exposure to people with infections. Avoid swimming and use care when showering. Obtain a Medic-Alert bracelet.

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action?

Reset the degrees of flexion or extension according to comfort.

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

Restrain in a car seat in the back seat in a semi-reclined, rear-facing position.

The nurse considers the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Which are correct about this protocol? Select all that apply.

The surgeon is the person that marks the area of the operative procedure. The site marking is done before the client is brought to the surgical suite in the operating room.

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

"I need to be sure to place my cup of coffee on the counter."

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?

"We will be sure not to leave hot liquids unattended."

A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)?

A bottle of alcohol

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?

Activate the fire alarm

A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply.

Avoid activities that involve pulling or pushing. Do not lift objects weighing more than 5 pounds. Do not climb stairs until after the follow-up appointment with the surgeon.

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

Blotting up the spill with a face cloth or cloth towel

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?

Closes the roller clamp on the IV tubing

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.

Pedal pulses Capillary refill Color of the extremity Temperature of the skin Presence of numbness

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.

Question the client about feelings of dizziness. Put the client's shoes on to help the client avoid slipping on the floor during the transfer. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply.

Socialize with the restrained client. Remove the restraint and perform range of motion activity. Reapply the restraint after assisting the client to the bathroom.

A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which client action shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable?

The client adjusts the setting downward slightly.

The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply.

Time the start and stop of the seizure. Apply oxygen at 2L with nasal cannula. Turn the client to the side and do not restrain. Note the distinguishing characteristics of the seizure. Turn on the suction machine with oral catheter.

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply.

Use a friction-reducing slide sheet. Use a mechanical lift to move the client. Keep elbows close and work close to the body. Obtain assistance of a second caregiver to assist with mechanical aids.

A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?

"Let me go over your prescribed medications with you again."

The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Alternating air pad

A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply.

Monitoring the skin around the stoma site for skin irritation Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube

The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take? Select all that apply.

Place a gait belt on the client. If stretch bands are used, reinforce the correct use. Observe for any signs/symptoms of dizziness the first time the client gets out of bed. After the client sits on the side of the bed, remind the client to stand on the unaffected leg.

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method?

Placing the needle and syringe in a puncture-resistant container

The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take?

Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.

A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply.

Removing any toy with bright blinking lights Keeping the sides rails of the child's bed padded Turning the infant on the side during any seizure Having oxygen and suction available at the bedside

A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.

Restraints Padded tongue blade

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply.

Securing the oxygen tubing to the client's bottom sheet Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible

The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?

There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.

Wearing gloves when emptying the client's bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the client's room Wearing a lead apron when providing direct care to the client

The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention should the nurse institute next for the client?

Wrap a light roll of gauze to cover the IV site.

A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work and they feel isolated and fearful. The nurse should suggest which to the mother?

"You should seek community after-school programs or activities for your children."

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.

Eat a nutritious diet with adequate protein. Use a pressure relief pad while in a wheelchair. Check the bottom sheet for wetness and wrinkles.

The nurse is assigned to the care of a client who is being admitted to a facility. The nurse notes which observations as indications the client likely has a hearing deficit? Select all that apply.

The client answers questions incorrectly. The client states she quit attending social events. The client does not respond to a person unless facing the speaker.

The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions should the nurse take? Select all that apply.

Place the client flat in bed. Notify the registered nurse of the drainage.

The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L).Based on this laboratory result, which actions should the nurse include in the plan of care? Select all that apply.

Testing stools and urine for blood Using a soft toothbrush for mouth care