Free NCLEX RN Practice Test
Question 1 of 5.
An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
A. An alternate method should be tried prior to applying a restraint.
B. Confused clients are almost always safer in restraints.
C. Restraints must be removed and the client reassessed at least every 2 hours.
D. A written policy for application of restraints must be in place.
E. The most restrictive restraint should be applied.
F. The nurse does not need an order for a restraint if the client is in danger.
Explanation: Alternatives (A), reassessment every 2 hours (C), and a written policy (D) are required for restraints. Confused clients aren't always safer (B), most restrictive (E) is incorrect, and an order is needed (F).
Question 2 of 5.
The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
A. I should have a bottle of Ipecac for each of my children.
B. I should induce vomiting if my child swallows lighter fluid.
C. Giving my child water or milk may help dilute the poison.
D. Proper storage is the key to poison prevention in the home.
Explanation: vomiting contraindicated when child ingests hydrocarbons due to danger of aspiration
Question 3 of 5.
A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?
A. Administer oxygen.
B. Turn her to the right side.
C. Provide adequate hydration.
D. Start antibiotics.
Explanation: adequate hydration is a priority for any client with sickle cell crisis
Question 4 of 5.
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique?
A. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
B. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
C. The nurse packs wet gauze into the incision without overlapping it onto the skin.
D. The old dressing is saturated with sterile saline before it is removed.
Explanation: if wet dressing touches skin it could cause skin breakdown
Question 5 of 5.
The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for
A. a client with Alzheimer’s requiring assistance with feeding.
B. a client with osteoporosis complaining of burning on urination.
C. a client with scleroderma receiving a tube feeding.
D. a client with cancer who has Cheyne-Stokes respirations.
Explanation: standard, unchanging procedure
Related Questions