NCLEX - Safe and Effective Care Environment

A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching?

"I will bend at the waist, keeping the halo vest straight to pick up items."

The nurse discovers that one of her assigned clients is bleeding excessively from an abdominal incision. The nurse gives specific prescriptions to an unlicensed assistive personnel (UAP) to attend to the other clients and tells another nurse to call the primary health care provider immediately. In this situation, the nurse is implementing which leadership style?

3.Autocratic

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?

3.Blotting up the spill with a face cloth or cloth towel

A client is placed on hydrate sedative-hypnotic for short-term treatment. Which nursing action indicates an understanding of the major side effect of this medication?

3.Instructing the client to call for ambulation assistance

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

3.Remain with the client until the anxiety decreases.

The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply.

3.Request that the client perform undemanding, self-care tasks. 4.Reinforce teaching the client techniques to maintain present reality. 5.Assist the client to reestablish relationships with significant others.

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address which client need?

3.Safety and security

The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply.

3.Wear gloves and gown while in the room caring for the client. 4.Use soap and water, not alcohol-based hand rub, for hand hygiene.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action?

Call the nursing supervisor.

A client receiving a high cleansing enema complains of pain and cramping. Which corrective action is most appropriate for the nurse to take?

Clamp the tubing for 30 seconds and restart the flow at a slower rate.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety?

Assign a staff member to the client who will remain with him or her at all times.

The nurse determines that the client diagnosed with neutropenia needs further teaching if which statement is made by the client?

"I will include plenty of fresh fruits in my diet."

The nurse is providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton. Which statement by the client indicates an understanding regarding the application of this medication?

"I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application."

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching?

"I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."

The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching?

"I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?

"I will place a steam vaporizer in my child's bedroom."

A client with tuberculosis (TB) will be treated with isoniazid and rifampin. The nurse is reinforcing instructions for the client regarding these medications. Which statement should the nurse plan to provide to the client?

"The entire prescribed course of the medication needs to be completed."

A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period?

"The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions."

Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?

"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."

A client has been instructed by the primary health care provider to alternate the use of hydrogen peroxide and glycerin eardrops to loosen an impacted accumulation of earwax. The nurse gives the client which directions to accomplish this daily procedure safely and independently?

"Use the solutions at body temperature for 7 to 14 days."

The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn."

The nurse is assisting in developing a plan of action for the emergency department in the event of an internal fire. Which should the nurse include in the plan? Select all that apply.

1.Direct ambulating clients to walk to a safe location. 4.Remove all clients from danger before attempting to extinguish the fire. 5.Move bedridden clients away from the fire area by use of beds or stretchers.

The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions in response to this client's medication refusal? Select all that apply.

1.Document the refusal of medication. 2.Notify the registered nurse. 3.Ask the client why he is refusing the medication.

The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure which need is met?

1.Safety with activities

The nurse is caring for a client who will have insertion of an internal cervical radiation implant. Which interventions should the nurse review with the client to prepare her for this procedure? Select all that apply.

1.The client's activity will be bed rest. 2.The client will have an indwelling urinary catheter placed. 3.Caregivers will wear lead shields while caring for the client.

A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem?

Consciously think about walking over imaginary lines on the floor.

A licensed practical nurse (LPN) is administering medications to a client who has difficulty swallowing. A time-released film-coated medication is prescribed and the client is unable to swallow the pill. Which action by the LPN is most appropriate?

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

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.

The nurse is assisting in the preparation of a client for a blood transfusion. Which item is the most important for the completion of the identification process?

Identification bracelet

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

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

The nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse should avoid which action?

Obtaining the specimen from the urinary drainage bag

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. What should the nurse tell the client to provide greater reassurance?

The cane has a flared tip with concentric rings to provide stability.

The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now?

The nurse should extend one leg to use to slide the client's body down to the floor.

A bone marrow aspiration is scheduled for a client suspected of having leukemia. What intervention does the nurse anticipate will be done to protect the aspiration site and client from becoming infected?

The site will be cleansed thoroughly with an antiseptic and allowed to air dry before the procedure.

The nurse has reinforced client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching?

"Crutch tips will not slip, even when wet."

The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action?

4.Pick up the implant with long-handled forceps and place into a lead container.

A client reports having had two bowel movements this morning and refuses a dose of docusate sodium. After appropriately charting in the medication administration record, which action should the nurse take?

2.Make a notation regarding the client's refusal in the nurse's notes.

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

2.Positioning a box that is to be lifted between the knees

The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority?

2.Removing the client from any immediate danger

The nurse knows that litigation involving nurses is common because of which reasons? Select all that apply.

1.Clients are better educated about health care. 2.Clients are better informed about their rights. 4.Clients have a higher expectation about the care they receive.

A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential postprocedure nursing intervention?

1. Monitoring for the gag reflex

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.

1. Securing the oxygen tubing to the client's bottom sheet 5. 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 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.

1. The surgeon is the person that marks the area of the operative procedure. 4. The site marking is done before the client is brought to the surgical suite in the operating room.

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse should include which actions to safely administer the medication? Select all that apply.

1. Wear gloves while administering the injected medication. 3. Dispose of the needle and syringe in a puncture-resistant container.

The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the primary health care provider regarding this client's condition? Select all that apply.

1."I am concerned this client has Kawasaki's disease. Can you please come assess this client?" 2."This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days." 4."I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." 5."I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that the need for further teachingis necessary when the client makes which statement?

1."I need to breastfeed my baby."

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

1.A client who requires a 24-hour urine collection

The nurse is reviewing the record of a client who has been prescribed baclofen. Which disorder should alert the nurse to contact the primary health care provider (PHCP)?

1.A seizure disorder

The nurse is caring for a client who has refused to take an oral medication. The nurse tells the client that the nurse will hold the client down and give the medication by injection if the client doesn't take the oral medication. The nurse then takes the client's bathrobe so the client will have to remain in his room. Which intentional torts has this nurse committed? Select all that apply.

1.Assault 3.False imprisonment

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply.

1.Change the password for entering computer files at least monthly. 2.Shred the printout of the nurse's flowchart at the end of the nurse's shift. 3.Use own user name and password when logging into the computer system.

A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions should the nurse include in planning care for this client? Select all that apply.

1.Check temperature at least every 4 hours. 2.Monitor white blood cell count daily as prescribed. 4.Remove fresh flowers or plants from the client's room.

The nurse has been asked to serve on the health care facility ethics committee and knows that this committee serves which purposes? Select all that apply.

1.Education 2.Case consultation 4.Process ethical dilemmas

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 UAP 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?

1.Every 2 hours

The nurse is aware that criminal offenses would have which characteristics as opposed to civil offenses? Select all that apply.

1.It is offensive to society in general. 2.It is detrimental to society as a whole. 4.It involves offenses such as robbery, murder, and assault. 5.It will result in punishment whose purpose is to deter further crimes.

The licensed practical nurse (LPN) renders aid at an automobile accident where several victims sustained injury. Which actions should the LPN take to offer first aid assistance? Select all that apply.

1.Look for Medic-Alert bracelets. 2.Attend the most seriously injured first. 3.Try to determine the mechanism of injury.

In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies should the nurse bring to the child's room to prevent the transmission of the virus?

1.Mask and gloves

Following a cleft lip repair, the nurse reinforces instructions to the parents of the infant. Which of the instructions should be given to the parents of the infant? Select all that apply.

1.Monitor frequency of diaper changes. 2.Cleanse the surgical site with normal saline 5.Apply prescribed antibiotic ointment to the surgical site.

The nurse is caring for a child with a platelet disorder and should expect which prescriptions from the primary health care provider? Select all that apply.

1.Observe for bleeding. 2.Encourage the child to rest. 5.Assist the registered nurse (RN) with blood transfusions.

A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the primary health care provider's prescription should the nurse question?

1.Obtain a throat culture.

The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply.

1.Oxygen 2.Suction machine 3.Prescribed diazepam 6.Padding for the side rails

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 6.Presence of numbness

The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?

1.Place the client on one-to-one suicide precautions.

A group of nurses are reinforcing instructions on health and safety management to survivors of a hurricane before they leave their temporary shelter and return home. Which instructions should the nurses include? Select all that apply.

1.Wash hands with soap and water frequently. 2.Bring water to a rolling boil for 3 to 5 minutes and cool before drinking. 5.Add 16 drops of chlorine bleach to a gallon of water and let stand for 30 minutes before drinking.

The nurse is educating a community group about risk factors for suicide and knows a member needs further teaching when which criteria are chosen as risk factors? Select all that apply.

3.Age less than 32 years 4.Practicing a religion 5.Married over 10 years

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply.

2. Open the distal flap of a sterile package first. 3.Prepare the sterile field just before the planned procedure. 6.Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

The nurse is reinforcing instructions about home safety measures regarding medications and toxic substances to a parent. Which parent statements indicate a need for further teaching? Select all that apply.

2."I need to refer to medication as 'candy' only when really necessary." 5."I can place several medications in the same bottle if I am going for an overnight trip."

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply.

2."Mass casualty events do not require an increase in the number of staff that are needed." 3."A mass casualty event occurs only within the heath care facility and could endanger staff." 5."A mass casualty event occurs if a fight between visitors occurs in the emergency department."

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. Which statements indicate prevention of transmission of tuberculosis? Select all that apply.

2."My family and I will practice good hand hygiene." 3."I will discard disposable tissues into a plastic bag." 4."I will cover my mouth when I cough, sneeze, or laugh."

A nurse is participating in a disaster drill. A participant wearing a yellow tag asks the nurse, "What does the yellow tag mean?" Which response by the nurse is accurate?

2."The yellow tag means you will be seen in 30 minutes to 2 hours."

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

2.A method of promoting quality care and risk management

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which indicates the need for further action and analysis?

2.A postoperative client who develops a cough and a fever

The nurse is caring for a client who is receiving intramuscular antibiotics. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want the medication to be given. The nurse tells the client that the medication is necessary and administers the medication. With which crime can the client legally charge the nurse as a result of the nursing action?

2.Battery

A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms indicate that the client's bleeding is caused by placenta previa? Select all that apply.

2.Bright red vaginal bleeding 3.Lack of uterine contractions

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 actions? Select all that apply.

2.Check the placement of the tube. 5.Aspirate the contents from the nasogastric tube. 6.Observe the characteristics and pH of the aspirate from the nasogastric tube.

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care?

2.Maintaining standard precautions at all times while caring for the neonate

The nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention?

2.The tertiary level of prevention

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections? Select all that apply.

2.Use indwelling urinary catheters judiciously. 3.Remove indwelling catheters when no longer needed. 4.Use strict aseptic technique when inserting all urinary catheters.

The nurse is planning the client assignments for the day. Which is an appropriate assignment for the unlicensed assistive personnel (UAP)?

3.A client who requires a 24-hour urine collection

Several clients are awaiting treatment in an outpatient mental health crisis treatment center. Which client should be treated first?

3.A client who says that voices sponsored by the FBI are telling him to stab his roommates

The nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad because "his feet are always cold at night." The nurse should incorporate which concept when formulating a response to the family member?

4.Older adults often have slower neurological response times and are therefore more at risk for burns.

Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that she is unable to obtain informed consent from the client because the client has received opioid analgesics and is sedated. The LPN understands that which action should be implemented?

4.Obtaining a telephone consent from a family member and ensuring that the oral consent is witnessed by two persons

A nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse must assign four clients and has a licensed practical nurse (LPN) and three unlicensed assistive personnel (UAP) on a nursing team. To which client should the nurse assign the LPN?

4.A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle attached to a syringe containing a clear liquid into the antecubital area. Which action would be the appropriate initial action by the nurse?

4.Call the nursing supervisor.

The nurse is giving a bed bath to an assigned client. An unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which?

4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which represents the legal ramifications associated with the RN's behavior?

4.No charge will be made against the RN because the RN's actions are reasonable.

The nurse is caring for a postoperative client who has been NPO and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priorityitem should the nurse place at the client's bedside?

4.Suction equipment

The nurse has a prescription to give a first dose of hydrochlorothiazide to an assigned client. The nurse should question the prescription if the client had a history of allergy to which item?

4.Sulfa drugs

The nurse on the day shift receives client assignments for the day. Which assigned client should the nurse check first?

A client who was admitted during the night because of a severe exacerbation of asthma

The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan?

Administering medications that will dilate the pupil

A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it?

Documenting task completion at the end of the day

A nursing student is preparing to conduct a clinical conference, and the topic is hepatitis in children. The nursing instructor advises the student to further research the topic if the student plans to include which information in the discussion?

Enteric precautions are necessary for hepatitis B (HBV) but not for hepatitis A (HAV).

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?

Has the client open the gift with the nurse present

Which infection control method should the nurse determine to be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure?

Hepatitis B vaccine

The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. The nurse reinforces which instruction to the victim in the discharge plan?

Information regarding the location of shelters

Which instructions should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive?

Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.

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 is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which is the appropriate nursing action?

Tell the client that it is necessary to notify the primary health care provider of the client's request.

The nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to an unlicensed assistive personnel (UAP). The UAP notifies the nurse that the client's vital signs are elevated, and the client is complaining of pain and dyspnea. Which is appropriate regarding the nurse's next action?

The nurse checks the client and gathers additional data before calling the primary health care provider.

A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to follow which practice to decrease the possibility of spreading the infection?

Wear a mask when in contact with people outside of the family until medications are effective.

The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action?

Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.