NCLEX Safety

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which action?

Check the placement of the tube.

The nurse plans to admit a client who has seizure precautions prescribed. Which pieces of equipment should be available at the client's bedside in the hospital room? Select all that apply.

Clean gloves 5. Oxygen with nasal cannula setup 6. Suction machine with oral catheter

The nurse is caring for a client who has hand restraints. How often should the nurse assess the skin integrity of the restrained hands?

Every 30 minutes

A client who is recovering from a brain attack (stroke) has residual dysphagia. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity?

Giving the client thin liquids

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

Gown and gloves

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric tube. The nurse checks the residual and obtains an amount of 200 mL. Which action should the nurse take?

Hold the feeding.

The nurse is preparing to administer an acetaminophen (Tylenol) suppository to a child. The nurse plans which action?

Insert the suppository 1 to 2 cm into the rectum.

After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?

Institute contact precautions.

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 health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that the client needs further teaching if the client verbalized which statement?

Keep the oxygen concentrator as close to the room wall as possible.

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

A client recovering from a scheduled cesarean delivery

A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measure is necessary when caring for this client?

Monitoring the skin around the stoma site for skin irritation

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 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 caring for a client with pneumonia who is to receive oxygen via nasal cannula. To provide a safe delivery of the oxygen the nurse should avoid which action?

Secures the oxygen tubing to the client's bottom sheet

The nurse is preparing to begin a continuous tube feeding on a client with a nasogastric tube. In which position should the nurse place the client for safe administration of the tube feeding?

With the head elevated 45 degrees

The nurse assists to conduct a home safety assessment with a client preparing for discharge, and the client tells the nurse that a space heater is used to heat the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater?

The space heater needs to be placed at least 3 feet from anything that can burn.

The emergency department 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 a fever. 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 immediately assists the client out of the room. Which is the next nursing action?

Activate the fire alarm.

The nurse is inserting an indwelling urinary catheter into the urethra of a client. As the nurse inflates the balloon, the client complains of discomfort. Which is the appropriate nursing action?

Aspirate the fluid, advance the catheter further, and reinflate the balloon.

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

A licensed practical nurse (LPN) is administering medications to a client with chronic rheumatoid arthritis. The client has difficulty swallowing, and the film-coated form of diflunisal is prescribed. Which action by the LPN is most appropriate?

Consult with the registered nurse (RN) about contacting the health care provider (HCP) regarding a medication change.

The nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, which should the nurse avoid to minimize the chance for further injury?

Delays in responding to call light

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 prepares to administer a prescribed dose of scopolamine (Transderm-Scōp). The nurse should monitor for which side effect of this medication?

Dry mouth

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.

Obtain a Medic-Alert bracelet. 4. Prevent debris from entering the stoma. 5. Avoid exposure to people with infections. 6. Avoid swimming and use care when showering.

The nurse is preparing to change the neck ties on a tracheostomy tube. Which action should the nurse take?

Obtain a second health care team member to assist.

The nurse enters the room to find that the client's trash can is in flames. The nurse should take which action first?

Remove the client from the room.

A client is being discharged to home following spinal fusion with insertion of rods. For which home environment situation should the nurse suggest a consultation with the continuing care nurse?

The bedroom and bath are on the second floor of the home.

A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which action by the client 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 is performing an environmental assessment in the home of an older client. Which requires immediate attention?

Unsecured scatter rugs

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal, how should the nurse position the client?

Upright in a chair

The registered nurse (RN) tells a licensed practical nurse (LPN) that the health care provider has prescribed a hypotonic intravenous (IV) solution for a client. Which IV solution should the LPN obtain for administration to the client?

0.45% saline

The nurse is monitoring the laboratory results of a 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

The nurse is caring for a child following a cleft palate repair who has wrist 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 preparing to reposition a dependent client who weighs more than 250 pounds. Which intervention is best for the nurse to consider when moving this client?

Find someone who can help.

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome who requires an injection. The nurse should perform which action to dispose of the needle after the medication is given?

Place the needle and syringe in a puncture-resistant container.

The nurse enters a laundry room to empty a bag of dirty linens and discovers that there is a fire in the laundry room. The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher to extinguish the fire. Which is the first action when using the fire extinguisher?

Pulling the pin on the fire extinguisher

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?

Water pad

The nurse has just been told by the health care provider that a prescription has been written to administer an iron injection to a client. The nurse anticipates giving the medication by which method?

Z-track

The nurse is reinforcing instructions about home safety measures to a parent. Which statement by the parent indicates a need for further teaching?

"I need to refer to medication as 'candy' only when really necessary."

A client is to receive medication via patient-controlled analgesia (PCA), and the nursing instructor asks the nursing student caring for the client to describe the use of the PCA. The instructor determines that the student needs further teaching about the PCA when the student makes which statement?

"Clients using PCA initiate the infusion by programming a pump."

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 determines that the client understands the proper fitting of the crutches when he states that which amount of space should be between the axilla and the top crutch pad?

1½ to 2 inches

The nurse is preparing to initiate a tube feeding for a client, and the health care provider has prescribed the use of an electronic feeding pump. The nurse brings the pump to the bedside to plug the pump cord into the wall and discovers that there is no available outlet in the wall socket. Which action should the nurse implement?

Contact the electrical maintenance department for assistance.

The nurse is assisting in developing a plan of care for an older client to prevent a fall. Which action would be least likely to prevent a fall?

Keeping the bathroom light off at nighttime

The nurse assists a health care provider with the insertion of a Miller-Abbott tube. After insertion of the tube, the nurse should assist the client to which position?

On the right side

The nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers which information?

That aspiration is a primary concern

The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which in the plan of care? Select all that apply.

1. Allowing the client sufficient time to eat 2. Providing oral hygiene after each meal 3. Maintaining a suction machine at the bedside

A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply.

1. Aspirin 2. Furosemide (Lasix) 5. Gentamycin (Garamycin)

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.

1. Pedal pulses 2. Capillary refill 3. Color of the extremity 4. Temperature of the skin

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.

1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to the client

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.

2. Removing any toy with bright blinking lights 3. Keeping the sides rails of the child's bed padded 4. Turning the infant on the side during any seizure

The nurse initiates a prescription from the health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply.

3. Adequacy of circulation in the body area that is restrained 4. Type of restraint and body area where the restraint was applied 5. Communication with client and family member about need for restraint 6. The alternative measures that were attempted before restraints were applied

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.

3. Homeopathy 4. Herbal supplements

The nurse is assigned to the care of a client with an unsealed internal radiation source. During an 8-hour shift, the nurse plans the care to avoid spending more than how much time in the client's room?

30 minutes

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide (Lasix), penicillin (Nafcillin) and ibuprofen (Motrin). He has received ibuprofen (Motrin) twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool? Refer to figure.

9 total points (moderate risk)

A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. How should the nurse transfer the client from the stretcher to the bed?

A slider board and the assistance of four people

The nurse is assigned to care for a client experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?

Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

The nurse reinforces teaching a client on how to administer enoxaparin (Lovenox) subcutaneously. The nurse determines that the client understands the correct procedure if the client does which on a return demonstration?

Bunches the skin before injection

A sublingual nitroglycerin (Nitrostat) tablet administered to a client for chest pain has relieved the pain and the client states he feels comfortable now. The nurse further assesses the client and then ensures that the client has which important item within easy reach before leaving the room?

Call bell

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires a security device (wrist restraints). The nurse determines that the nursing assistant is providing safe care if the nurse observes the UAP checking skin integrity by completely removing the client's wrist restraints at which time interval?

Every 2 hours

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury?

Explore the adolescent's knowledge of gun safety.

The nurse is turning a postoperative client who had extensive spinal surgery on the previous day. Which turning intervention or position would be best for repositioning this client?

Logrolling

The nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an internal cervical (vaginal) radiation implant. Which action should the nurse suggest including in the plan of care for the client?

Place a radiation sign on the door outside of the client's room.

The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? Select all that apply.

Provide adequate lighting. 3. Ensure that frequently used items are easily accessible. 4. Have the bedside stand and overbed tray table within reach.

The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?

Remove the clients from the waiting room.

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The health care provider visits and prescribes restraints if needed. Which action is 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.

The nurse obtains a prescription from the health care provider to restrain a client using a jacket (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, should indicate unsafe application of the restraint?

The restraint straps are safely secured to the side rails.

The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Which location should the nurse select to administer the medication?

Vastus lateralis muscle

A health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

Placing the heating pad under the client

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 statement by the client indicates adequate understanding of cold therapy treatment?

"I should wrap the frozen ice pack in a warm towel to help adjust to the cold."

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."

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. The nurse should explore with the mother which suggestion to decrease the children's sense of isolation and fear?

"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.

1. Eat a nutritious diet. 2. Use a pressure relief pad while in a wheelchair. 4. Check the bottom sheet for wetness and wrinkles.

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 told that a client will be admitted to the hospital for a radiation implant for bladder cancer. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Admit the client to a private room.

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform?

Aim at the base of the fire.

The nurse is preparing to administer medication through a nasogastric (NG) tube that is connected to suction. Which indicates the accurate procedure for medication administration?

Clamp the NG tube for 30 minutes after medication administration.

The nurse is assigned to assist in caring for a client who has had an autograft placed on the anterior lower extremity. Which activity should the nurse include in the plan of care?

Elevate and immobilize the surgical extremity.

The nurse is reinforcing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with security devices (hand restraints). How often should the nurse instruct the UAP to check the client's skin and circulation under the security devices?

Every 30 minutes

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?

Every hour

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should avoid which action when performing this procedure?

Placing suction on the catheter while introducing the catheter into the tracheostomy tube

The nurse is instructing a group of unlicensed assistive personnel in the principles of body mechanics. The nurse determines that a student is using the principles appropriately if the nurse observes the nursing assistant doing which action?

Positioning a box that is to be lifted between the knees

The nurse is reinforcing instructions to a client with chronic vertigo. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms?

Removing throw rugs and clutter in the home

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that the client needs 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 semireclined, rear-facing position.

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 item is least appropriate to use and could cause harm to the client?

Restraints

The nurse is collecting data from a client and is observing the client ambulate with the use of a cane. For which client action, when observed, should the nurse intervene and suggest a physical therapy referral?

The client moves the cane and the unaffected side together.

The nurse is administering intramuscular iron to an assigned client. The nurse should take which action to avoid skin staining around the injection site?

Use a Z-track method for administration.

The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000/mm3. Based on this laboratory result, which action should the nurse include in the plan of care?

Using a soft toothbrush for mouth care

The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which?

Using products with lemon or alcohol

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

1. Do you have a history of seizures? 2. How long have you been using ginkgo? 3. Do you have a history of a clotting disorder? 4. Have you been diagnosed with diabetes mellitus?

The nurse is preparing to apply a mitten restraint to the client's hand. The nurse does which to ensure that the restraint is applied correctly? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

Makes sure that two fingers can be inserted under the restraint

The registered nurse is preparing to insert a nasogastric (NG) tube in a client and asks the licensed practical nurse (LPN) to obtain supplies needed for the procedure. Which supply obtained by the LPN indicates a need for further teaching regarding this procedure?

Oil-soluble lubricant

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