NCLEX Reviewers » NCLEX Sample Questions

Management of Care NCLEX Questions Answers and Rationale

admin — Thu, 29 Jul 2010 06:23:00 +0000

1.    Answer B. Calling the supervisor is a secondary measure after confronting the nurse and relieving the nurse of her duties. You cannot always assume the supervisor will be immediately available, and client safety should be addressed first. When another nurse is unable to perform her nursing duties due to substance abuse, she should not be allowed to continue them, as client safety is a primary concern. Ignoring the situation is against the professional code of conduct for nurses. Angelina needs to be relieved of her duties. She probably would not benefit from a lecture in her condition.
2.    Answer D. Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks would be appropriate for a PN or RN to do since they are advanced skills or require evaluation.
3.    Answer B. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.
4.    Answer D. In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared.
5.    Answer B. Secrets are inappropriate in therapeutic relationships and are counterproductive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.
6.    Answer B. This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client.
7.    Answer C. Obtain more details of the client’s claim of abuse. The advocacy role of the professional nurse as well as the legal duty of the reasonable prudent nurse requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, further assessment, before documentation or the reporting of the complaint.
8.    Answer D. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.
9.    Answer B. Assign 1 of the nursing staff to visit the client regularly. Regular, frequent, planned contact by 1 staff member provides continuity of care and communicates to the client that care will be available when needed.
10.    Answer D. Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed.
11.    Answer B. The nurse must maintain the client’s right of confidentiality. Since he is not the client’s physician and does not have a medical need to see her chart, he should not be allowed to read the chart without written permission from the client, who is above the age of majority. Since he is not the client’s physician and does not have a medical need to see her chart, he should not be allowed to read the chart without written permission from the client, who is above the age of majority. It is not the attending surgeon who can give permission for him to review the chart, it is the client. The client must give written permission for unauthorized persons to review her chart. This client had surgery today and is probably not alert enough to give legal permission, which must be written.
12.    Answer A. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities
13.    Answer B. It cannot be legally assumed that the client consents to a procedure for which he has not given consent. This is not legally defensible. All invasive procedures require informed consent. The surgery is prescheduled and described as exploratory and therefore is not an emergency. If the client is an adult and has not been declared incompetent the client must sign the form. This client should not have surgery performed without written consent. The nurse must notify the physician immediately. The client has been premedicated for surgery and is not alert. He cannot give legal consent when under the influence of mind-altering drugs. The client is an adult and there is no evidence that he has been declared incompetent to make his own decisions. The surgery is exploratory. There is no indication it is for an immediately life-threatening condition. It is not appropriate to ask the next of kin to sign his consent form.
14.    Answer D. In addition to notifying the physician and documenting it, the nurse should complete an incident report. The physician must be notified. An incident report should be completed. However, no record of the incident report should appear in the nurse’s notes. The physician must be notified. An incident report should be completed. However, no record of the incident report should appear in the nurse’s notes. The physician must be notified of the medication error. An incident report should be completed. However, no record of the incident report should appear in the nurse’s notes. The nurse should document that the physician was notified and any assessments completed.
15.    Answer D. The need for family support is vital to prevent discouragement and depression. A volunteer will not take the place of family. The need for family support is vital to prevent discouragement and depression, even at the risk of offending the families of other patients. Loss of a breadwinner during the lengthy recovery process may add financial problems for the family. Guillain-Barré syndrome is characterized by the onset of ascending paralysis, which may include respiratory muscles. Persons with Guillain-Barré syndrome may remain ventilator-dependent for weeks, but have full consciousness. The prognosis for recovery from Guillain-Barré syndrome is good, but is very much dependent upon the level of supportive care during the acute stage.
16.    Answer D. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff.
17.    Answer B. An alert, oriented client should be asked to state her full name so that there is no confusion in identity. The ID bracelet will confirm identity when the client is not alert or oriented to person. Reading the name on the client’s ID bracelet is the most accurate way to confirm identity. Reading the client’s medical record will not confirm identity. The roommate is not an accurate source for client identification.
18.    Answer C. This response explains the clients behavior without belittling the nursing assistant’s feelings. The nursing assistant is encouraged to help solve the problem with the nurse.
19.    Answer D. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.
20.    Answer D. The RN may delegate the application and care of rectal pouches to a nursing assistant, who should be capable of performing this task .

Management of Care NCLEX Questions

admin — Wed, 28 Jul 2010 06:14:30 +0000

1.    Angelina, an R.N., reports to work looking unkempt. Maegan, another R.N., approaches when she notices her using uncoordinated movements. Angelina’s breath reeks of peppermints and Maegan suspects Angelina may be intoxicated. What is the best initial nursing action for Maegan to take?
a.    Call the supervisor and report Angelina.
b.    Confront Angelina, saying that she feels she is intoxicated, and relieve her of her nursing duties immediately.
c.    Ignore the situation.
d.    Give Angelina a lecture about substance abuse and do nothing else.

2.    Carol has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
a.    To observe the type and amount of nasogastric tube drainage
b.    Monitor the client for nausea or other complications
c.    Irrigate the nasogastric tube with the ordered irrigant
d.     Perform nostril and mouth care

3.    Britney is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that:
a.    a referral is needed to the psychiatrist who is to provide the client with answers
b.    the client has a right to know about the prescribed medications
c.    such education is an independent decision of the individual nurse whether or not to teach clients about their medications
d.    clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

4.    James with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements?
a.    "I am sorry. Referral information can only be provided by the client’s providers"
b.    "I can never give any information out by telephone. How do I know who you are?"
c.    "Since this is a referral, I can give you this information"
d.    "I need to get the client’s written consent before I release any information to you"

5.    A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is:
a.    "I must document and report any important information."
b.    "I can’t make such a promise."
c.    "That depends on what you tell me."
d.    "I must report everything to the treatment team."

6.    Helen, a nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with:
a.    Dopamine drip IV with vital signs monitored every 5 minutes
b.    a myocardial infarction that is free from pain and dysrhythmias
c.    a tracheotomy of 24 hours in some respiratory distress
d.    a pacemaker inserted this morning with intermittent capture

7.    A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first:
a.    focus on reality orientation to place and person
b.    assist with the report of the client’s complaint to the police
c.    obtain more details of the client’s claim of abuse
d.    document the statement on the client’s chart with a report to the manager

8.    John, a client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to:
a.    ask to not be assigned to this client or to work on another unit
b.    tell the client that such behavior is inappropriate
c.    inform the client that hospital policy prohibits staff to date clients
d.    discuss the boundaries of the therapeutic relationship with the client

9.    A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to:
a.    keep the client’s room door cracked to minimize the distractions
b.     assign 1 of the nursing staff to visit the client regularly
c.    reassure the client that 1 staff person will check frequently if the client needs anything
d.    arrange for each staff member to go into the client’s room to check on needs every hour on the hour

10.    The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
a.    Assign an RN to provide total care of the client
b.    Assign a nursing assistant to help the client with self-care activities
c.    Delegate complete care to an unlicensed assistive personnel
d.    Supervise a nursing assistant for skin care

11.    A 24-year-old woman had surgery today. Her father, a physician but not her surgeon, enters the nursing station and asks for her chart. The best action for the nurse to take is:
a.    to give him the chart as requested.
b.    not to allow him to read the chart.
c.    to ask the attending surgeon if it is permissible for him to read the chart.
d.    to ask the client if she wants him to read her chart.

12.    When assessing a client, it is important for the nurse to be informed about cultural issues related to the client’s background because:
a.    Normal patterns of behavior may be labeled as deviant, immoral, or insane
b.    The meaning of the client’s behavior can be derived from conventional wisdom
c.    Personal values will guide the interaction between persons from 2 cultures
d.    The nurse should rely on her knowledge of different developmental mental stages

13.    Robin, an adult male is scheduled for exploratory surgery this morning. After he is premedicated for surgery the nurse reviews his chart and discovers that he has not signed a consent form. The nurse’s action is based on which of the following understandings?
a.    Since the client came to the hospital consent is implied even if the consent for the surgery has not been signed.
b.    All invasive procedures require a consent form.
c.    The nurse should have him sign a consent form immediately
d.    The nurse should have the next of kin sign the necessary consent form

14.    Zantac is ordered for an adult client. The nurse mistakenly administered Xanax. What is the most appropriate action for the nurse to take?
a.    Notify the physician and document in the nurse’s notes that the physician was notified of the error.
b.    Notify the supervisor, complete a medication error incident report, and document in the nurse’s notes that an incident report was completed
c.    Notify the house supervisor, assess client carefully, and document only if adverse or untoward effects occur.
d.    Notify the physician, complete an incident report, and document the notification of the physician and any assessments made.

15.    A client with Guillain-Barré syndrome has been on a ventilator for three weeks, and can communicate only with eye blinks because of quadriplegia. The intensive care nursing staff sometimes have no time for this tedious communication process. The client’s family comes infrequently since they run a family-owned restaurant that does not close until visiting hours are over. How should the nurse respond to the family’s request for exemption from visiting hours?
a.    Arrange for a volunteer to stay with the client during the day to provide for socialization needs and to facilitate communication with staff.
b.    Explain to the family that consistency in enforcing rules is important to prevent complaints from the families of other clients.
c.    Suggest that the family visit in shifts during the normal visiting hours, since the client needs to sleep at night.
d.    Make an exception to visiting regulations because of the long-term nature of the client’s recovery and the need for family support.

16.    An adult client has continued slow bleeding from the graft after repair of an abdominal aortic aneurysm. Because of the client’s unstable condition, he is in the intensive care unit where visitors are limited to the family. The client insists on having a visit from a medicine man whom the family visits regularly. How should the nurse interpret this request?
a.    The principle of justice prohibits giving one client a privilege that other clients are not permitted.
b.    Faith healers do not meet the standards for clergy exemption from visitation rules.
c.    Medicine men are not approved by the hospital as legitimate health care providers.
d.    Provision of holistic care requires that the client’s belief system is honored.

17.    Mrs. Jefferson is an 88-year-old client at a long-term care facility. Prior to administering any medication or treatment to this client the nurse must confirm identity by:
a.    asking the client if she is Mrs. Jefferson.
b.    reading the client’s identification bracelet
c.    reading the client’s medical record.
d.    asking the roommate to state the client’s name.

18.    After working with a very demanding client, a nursing assistant tells the nurse, "I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again." The nurse’s BEST response is:
a.    "He has a lot of problems. You need to be patient with him."
b.    "I will talk with him and try to figure out what to do."
c.    "He is scared and taking it out on you. Let’s try to figure out what to do."
d.    "Ignore him and get the rest of your work done. Someone else can take care of him tomorrow."

19.    A client frequently compliments and invites the nurse to go out. The nurse should:
a.    Minimize further contact with the client
b.    Tell the client that his/her behavior is inappropriate
c.    Tell the client that hospital policy prohibits dating clients
d.    Discuss the boundaries of the relationship with the client

20.    Which one of the following could be safely delegated by the nurse to the nursing assistant?
a.    Observe a client’s self-administration of insulin
b.    Cleanse and dress a small decubitus ulcer
c.    Monitor a client’s response to physical therapy
d.    Apply and care for a client’s rectal pouch

Answers and Rationale will be posted soon…

More NCLEX review soon…

How to pass the nclex

Management of Care NCLEX Questions Answers and Rationale Share this on Facebook Tweet This! Email this via...
NCLEX Sample Questions for LEADERSHIP, MANAGEMENT, BIOETHICS AND RESEARCH 2 Share this on Facebook Tweet This! Email this via...
NCLEX Sample Questions for LEADERSHIP, MANAGEMENT, BIOETHICS AND RESEARCH Share this on Facebook Tweet This! Email this via...

Basic Care and Comfort NCLEX Practice Test Answers and Rationale

admin — Fri, 23 Jul 2010 07:44:00 +0000

View Questions

1.    Answer D. Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Using the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Sitting in a wheelchair would require too great hip flexion initially. Asking her family to visit would not facilitate the resumption of activities. Sitting in a chair would cause too much hip flexion. The client initially needs to be in a low Fowler’s position or taking a few steps (as ordered) with the aid of a walker.
2.    Answer A. It is important to measure intake and output, which should equal. Enteral feeding are hyperosmotic agents pulling fluid from cells into vascular bed. Water given before feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance.
3.    Answer C. Esophageal varices results from increased portal hypertension. In portal hypertension, the liver cannot accept all of the fluid from the portal vein. The excess fluid will back flow to the vessels with lesser pressure, such as esophageal veins or rectal veins causing esophageal varices or hemorrhoids.
4.    Answer A. Elevation of the head of the bed allows gravity to assist in decreasing the backflow of acid into the esophagus. Fluid does not flow uphill. The other three options all increase fluid backflow into the esophagus through position or increasing abdominal pressure.
5.    Answer D. Particularly in the elderly adults, therapeutic massage will help improve circulation and muscle tone as well as the personal attention and social interaction that a good massage provides. A massage is contraindicated in any condition where massage to damaged tissue can dislodge a blood clot.
6.    Answer C. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. All of the other foods do not affect LES pressure.
7.    Answer B. TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to hypertonicity of the solution. Option 1 is incorrect; medication therapy can continue during TPN therapy. Option 3 is incorrect; flushing is not required because the initiation of TPN does not require a client to remain on bed rest during therapy. However, other clinical conditions of the client may affect mobility issues and warrant the client’s being on bed rest.
8.    Answer B. Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed by bacterial action, and this action assists in the digestion of lactose. The freezing process further stops bacterial action so that limited lactase activity remains. Option 1 is incorrect; elimination of all dairy products can lead to significant clinical deficiencies of other nutrients. Option 3 is incorrect because drinking milk on an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because other foods, (especially fat) may decrease transit time and allow for increased lactase activity. Option 4 is incorrect because although individual tolerance should be acknowledged, spreading out the use of known dairy products will usually exacerbate clinical symptoms.
9.    Answer B. There is potential for a lowered pain tolerance to exist with diminished adaptative capacity.
10.    Answer C. Cutaneous stimulation allows the patient to have control over his pain and allows him to be in his own environment. Cutaneous stimulation increases movement and decreases pain.
11.    Answer A. Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.
12.    Answer C. Although all of the options above are correct, the first and most important piece of information in this client’s pain assessment is what the client is telling you about the pain –“the client’s report.”
13.    Answer B. Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults.
14.    Answer D. Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats
15.    Answer A. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.
16.    Answer A. When a person with weakness on one side uses a cane, there should always be two points of contact with the floor. When Ms. Kelly. moves the cane forward, she has both feet on the floor, providing stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane, which is even with the weak leg, provides stability while she moves the strong leg. She should not hold the cane with her weak arm. The use of the cane requires arm strength to ensure that the cane provides adequate stability when standing on the weak leg. The cane should be held in the left hand, the hand opposite the affected leg. If Ms. Kelly. moved the cane and her strong foot at the same time, she would be left standing on her weak leg at one point. This would be unstable at best; at worse, impossible
17.    Answer B. Mayonnaise in tuna salad is high in fat. The whole wheat bread has some fiber. This choice shows a low-fat soup (which would have been higher in fat if made with chicken or beef stock) and high-fiber bread and soup contents (both the vegetables and the legumes). Salad is high in fiber, but hard boiled eggs are high in fat. There is some fiber in the apples and walnuts. The walnuts are high in fat, as is the chicken.
18.    Answer A. Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy. Soreness of the gums is not related to immobility. Short-term memory loss is not related to immobility. Decreased appetite is unlikely to be related to immobility.
19.    Answer A. Iron deficiency anemia occurs commonly in children 6 to 24 months of age. For the first 4 to 5 months of infancy iron stores laid down for the baby during pregnancy are adequate. When fetal iron stores are depleted, supplemental dietary iron needs to be supplied to meet the infant’s rapid growth needs. Iron deficiency may occur in the infant who drinks mostly milk, which contains no iron, and does not receive adequate dietary iron or supplemental iron. Daily dietary intake is much more related to the diagnosis of iron deficiency anemia than is sociocultural, economic, and educational background of the family. Iron deficiency anemia in an infant is very unlikely to be related to gastrointestinal bleeding. Anemia during pregnancy is unlikely to be the cause of the infant’s iron deficiency anemia. Fetal iron stores are drawn from the mother even if she is anemic.
20.    Answer D. Foods high in bulk are appropriate. Exercise should be a part of a bowel training regimen. To assess the client for a bowel training program the factors causing the bowel alteration should be assessed. A routine for bowel elimination should be based on the client’s previous bowel habits and alterations in bowel habits that have occurred because of illness or trauma. The client and the family should assist in the planning of the program which should include foods high in bulk, adequate exercise, and fluid intake of 2500-3000 ml.

Basic Care and Comfort NCLEX Practice Test

admin — Thu, 22 Jul 2010 07:40:30 +0000

1.    Nurse Jessie is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?
a.    arranging for the wheelchair
b.    asking her family to visit
c.    assisting her to sit out of bed in a chair qid
d.    encouraging the use of an overhead trapeze

2.    What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
a.     measure intake and output.
b.    check albumin level.
c.    monitor glucose levels.
d.    increase enteral feeding.

3.    What is the pathological process causing esophageal varices is
a.    ascites and edema.
b.    systemic hypertension.
c.    portal hypertension.
d.    dilated veins and varicesitis.

4.     Which of the following interventions will help lessen the effect of GERD (acid reflux)?
a.     Elevate the head of the bed on 4-6 inch blocks.
b.    Lie down after eating.
c.    Increase fluid intake just before bedtime.
d.    Wear a girdle.

5.    What is the main benefit of therapeutic massages is:
a.    to help a person with swollen legs to decrease the fluid retention.
b.    to help a person with duodenal ulcers feel better.
c.    to help damaged tissue in a diabetic to heal.
d.    to improve circulation and muscles tone.

6.    Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)?
a.    Lettuce
b.    Eggs
c.    Chocolate
d.    Butterscotch

7.    Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)?
a.    Withhold medications while the TPN is infusing.
b.    Change TPN solution every 24 hours.
c.    Flush the TPN line with water prior to initiating nutritional support.
d.    Keep client on complete bed rest during TPN therapy.

8.    Which of the following should be included in a plan of care for a client who is lactose intolerant?
a.    Remove all dairy products from the diet.
b.    Frozen yogurt can be included in the diet.
c.    Drink small amounts of milk on an empty stomach.
d.    Spread out selection of dairy products throughout the day.

9.    Pain tolerance in an elderly patient with cancer would:
a.    stay the same.
b.    be lowered.
c.    be increased.
d.    no effect on pain tolerance.

10.    What is the main advantage of cutaneous stimulation in managing paint:
a.    costs less.
b.    restricts movement and decreases.
c.    gives client control over pain syndrome.
d.    allows the family to care for the patient at home.

11.    The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
a.    exercise doing weight bearing activities
b.    exercise to reduce weight
c.    avoid exercise activities that increase the risk of fracture
d.    exercise to strengthen muscles and thereby protect bones

12.    A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to
a.    have the client identify coping methods
b.    get the description of the location and intensity of the pain
c.    accept the client’s report of pain
d.    determine the client’s status of pain

13.    Which statement best describes the effects of immobility in children?
a.    Immobility prevents the progression of language and fine motor development
b.    Immobility in children has similar physical effects to those found in adults
c.    Children are more susceptible to the effects of immobility than are adults
d.    Children are likely to have prolonged immobility with subsequent complications

14.    After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?
a.    3 oz. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk
b.    3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
c.    A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
d.    3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

15.    A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
a.    A 79 year-old malnourished client on bed rest
b.    An obese client who uses a wheelchair
c.    An incontinent client who has had 3 diarrhea stools
d.    An 80 year-old ambulatory diabetic client

16.    Ms. Kelly. has had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects correct use of the cane?
a.    Holding the cane in her left hand, Ms. Kelly. moves the cane forward first, then her right leg, and finally her left leg
b.    Holding the cane in her right hand, Ms. Kelly. moves the cane forward first, then her left leg, and finally her right leg
c.    Holding the cane in her right hand, Ms. Kelly. moves the cane and her right leg forward, then moves her left leg forward.
d.    Holding the cane in her left hand, Ms. Kelly. moves the cane and her left leg forward, then moves her right leg forward

17.    The nurse is instructing a woman in a low-fat, high-fiber diet. Which of the following food choices, if selected by the client, indicate an understanding of a low-fat, high-fiber diet?
a.    Tuna salad sandwich on whole wheat bread.
b.    Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread
c.    Chef’s salad with hard boiled eggs and fat-free dressing
d.    Broiled chicken stuffed with chopped apples and walnuts

18.    An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?
a.    Stiffness of the right ankle joint
b.    Soreness of the gums
c.    Short-term memory loss.
d.    Decreased appetite.

19.    An eleven-month-old infant is brought to the pediatric clinic. The nurse suspects that the child has iron deficiency anemia. Because iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant’s parents?
a.    Normal dietary intake.
b.    Relevant sociocultural, economic, and educational background of the family.
c.    Any evidence of blood in the stools
d.    A history of maternal anemia during pregnancy

20.    A 46-year-old female with chronic constipation is assessed by the nurse for a bowel training regimen. Which factor indicates further information is needed by the nurse?
a.    The client’s dietary habits include foods high in bulk.
b.    The client’s fluid intake is between 2500-3000 ml per day
c.    The client engages in moderate exercise each day
d.    The client’s bowel habits were not discussed.

Answers and Rationale

More NCLEX review

Basic Care and Comfort NCLEX Practice Test Answers and Rationale Share this on Facebook Tweet This! Email this via...
Management of Care NCLEX Questions Share this on Facebook Tweet This! Email this via...
NCLEX Practice Test with Answers and Rationale Share this on Facebook Tweet This! Email this via...

Safety and Infection Control NCLEX Questions Answers and Rationale

admin — Sun, 18 Jul 2010 02:29:06 +0000

View Questions

1. Answer C. The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection.

2. Answer D. Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient’’s sputum is expected. A private room and BSI, along with good hand washing techniques, are the best defense against the spread of MRSA pneumonia.

3. Answer B. The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.

4. Answer A. Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag.

5. Answer B. Hands are the primary method of transmission of the common cold. The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected person. The tubercle bacillus is not transmitted by means of contaminated food. Contact with contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid, or cholera. The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating utensils.

6. Answer D. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence.

7. Answer B. Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow. This cleanses the wounds, especially those that are still open, and removes dead tissue. The client is taught to report changes in wound healing such as blister formation, signs of infection, and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing. The client must be aware that infection of the wound may occur; signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul smelling drainage must be reported immediately.

8. Answer D. The client needs frequent visits by the staff to orient him and to assess his safety. Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Putting the client in a bright, busy area would probably add to his confusion. The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client.

9. Answer B. The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed. People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. This statement is not true. As soon as the radiation source is removed (probably 36 to 72 hours after insertion), the client is no longer contaminated with radioactivity. Craft projects usually require the client to sit. The client must remain flat with very little head elevation during the time the rods are in place.

10. Answer C. There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves. Strict isolation requires the use of mask, gown, and gloves.

11. Answer D. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. The nurse should wash her hands after removing the soiled dressing and before donning the sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. However, the nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse.

12. Answer A. To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate. The amount of regular exercise is not the most important factor to assess. It is only indirectly related. The resting pulse rate is not related to preventing falls. The salt intake is not directly related to preventing falls.

13. Answer C. Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. If there is ever any doubt about the sterility of an instrument or dressing, it should not be used. The 4 X 4s should be soaked prior to donning the sterile gloves. Once the sterile gloves touch the bottle of normal saline they are no longer sterile. This statement indicates a need for further instruction.

14. Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client’s hygiene is poor.

15. Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client’s hygiene is poor.

16. Answer C. Needles that have been used to draw blood should not be recapped. If it is necessary to recap them, an instrument such as a hemostat should be used to recap. The hand should never be used. Gloves are not necessary when feeding, since there is no contact with mucus membranes. Although saliva may have small amounts of HIV in it, the virus does not invade through unbroken skin. There is no evidence in the question to indicate broken skin. Masks and protective eye wear are indicated anytime there is great potential for splashing of body fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a tracheostomy are likely to have blood in the sputum. There is no reason to restrict pregnant workers from caring for persons with AIDS as long as they utilize universal precautions.

17. Answer A. Direct contact is the mode of transmission for staphylococcus. Staph is not spread by coughing. Staph is not spread through oral secretions. Direct contact is required. Staph is not spread through oral secretions.

18. Answer A. The AIDS virus is spread through direct contact with body fluids such as blood and through sexual intercourse. Casual contact with other people does not pose a risk of transmission of AIDS. Unless the client is feeling very ill, there is no need for him to drop his college classes. Contact sports are not contraindicated unless there is a significant chance of bleeding and direct contact with others. Casual contact with other people does not pose a risk of transmission of AIDS. There is no need to limit casual contact with children.

19. Answer D. Drug use is a risk factor for AIDS. Multiple sex partners is a risk factor for AIDS. Birth control methods are important to prevent a baby from being born with the AIDS virus. The age at which sexual activity began it not relevant as it does not usually provide information that identifies the presence of risk factors for AIDS.

20. Answer C. Independently ambulating around the unit is not appropriate because the unit environment can change and injury could result. Assistance is necessary because of the client’s visual deficit. It is unlikely the client can see well enough to read the materials. Maneuvering safely after orientation to the room is a realistic goal for a person with impaired vision. Orienting the client to the room should help the client to move safely. Using the bedpan is an unnecessary restriction on the client as she can be oriented to the bathroom or to call for assistance.

More NCLEX review…

Safety and Infection Control NCLEX Questions Share this on Facebook Tweet This! Email this via...
NCLEX RN Example Test Questions with Answers and Rationale Share this on Facebook Tweet This! Email this via...
NCLEX Sample Questions Pediatric Nursing Part 2 Answers and Rationale Share this on Facebook Tweet This! Email this via...

Safety and Infection Control NCLEX Questions

admin — Fri, 16 Jul 2010 02:14:58 +0000

1.    A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST?
a.    Institute seizure precautions
b.    Assess neurologic status
c.    Place in respiratory isolation
d.    Assess vital signs

2.    A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client?
a.    Reverse isolation
b.    Respiratory isolation
c.    Standard precautions
d.    Contact isolation

3.    Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions?
a.    A diagnosis of AIDS and cytomegalovirus
b.    A positive PPD with an abnormal chest x-ray
c.    A tentative diagnosis of viral pneumonia
d.    Advanced carcinoma of the lung

4.    Which of the following is the FIRST priority in preventing infections when providing care for a client?
a.    Handwashing
b.    Wearing gloves
c.    Using a barrier between client’s furniture and nurse’s bag
d.    Wearing gowns and goggles

5.    An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a pre-employment physical. Although frightened about her diagnosis, she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible?
a.    Hands.
b.    Droplet nuclei.
c.    Milk products.
d.    Eating utensils.

6.    A 2 year old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action?
a.    Order a stat admission CBC.
b.    Place a urine collection bag and specimen cup at the bedside.
c.    Place a cooling mattress on his bed.
d.    Pad the side rails of his bed.

7.    A young adult is being treated for second and third degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement?
a.    “I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water.”
b.    “If any healed areas break open I should first cover them with a sterile dressing and then report it.”
c.    “I must wear my Jobst elastic garment all day and can only remove it when I’m going to bed.”
d.    “I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours.”

8.    An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is
a.    limit visits by staff.
b.    encourage family phone calls.
c.    position in a bright, busy area.
d.    speak soothingly and provide quiet music.

9.    Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure?
a.    She says to her husband, “Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food.”
b.    “I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital.”
c.    “I understand it will be several weeks before all the radiation leaves my body.”
d.    “I brought several craft projects to do while the radium is inserted.”

10.    The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff?
a.    The nurse aide is not wearing gloves when feeding an elderly client.
b.    A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing.
c.    A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.
d.    The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.

11.    The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to:
a.    interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing.
b.    congratulate the nurse on the use of good technique.
c.    discuss dressing change technique with the nurse at a later date.
d.    interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.

12.    Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is:
a.    Correct    illumination of the environment.
b.    amount of regular exercise.
c.    the resting pulse rate.
d.    status of salt intake.

13.    Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones understands the importance of maintaining asepsis?
a.    “If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled.”
b.    “If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline.”
c.    “If I question the sterility of any dressing material, I should not use it.”
d.    “I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s.”

14.    A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation?
a.    Masks should be worn with all client contact.
b.    Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
c.    Isolation gowns are not needed.
d.    A private room is always indicated.

15.    A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation?
a.    Masks should be worn with all client contact.
b.    Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
c.    Isolation gowns are not needed.
d.    A private room is always indicated.

16.    The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions?
a.    A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood.
b.    An aide wears gloves to feed a helpless client.
c.    An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy.
d.    A pregnant worker refuses to care for a client known to have AIDS.

17.    Jayson, 1 year old child has a staph skin infection. Her brother has also developed the same infection. Which behavior by the children is most likely to have caused the transmission of the organism?
a.    Bathing together.
b.    Coughing on each other.
c.    Sharing pacifiers.
d.    Eating off the same plate.

18.    Jessie, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS transmission has been effective when the client:
a.    verbalizes the role of sexual activity in spread of the disorder.
b.    states he will make arrangements to drop his college classes.
c.    acknowledges the need to avoid all contact sports.
d.    says he will avoid close contact with his three-year-old niece.

19.    Which question is least useful in the assessment of a client with AIDS?
a.    Are you a drug user?
b.    Do you have many sex partners?
c.    What is your method of birth control?
d.    How old were you when you became sexually active?

20.    Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital the day before scheduled surgery. The nurse’s preoperative goals for Mrs. M. would include:
a.    independently ambulating around the unit.
b.    reading the routine preoperative education materials.
c.    maneuvering safely after orientation to the room.
d.    using a bedpan for elimination needs.

Answers and Rationale