Nclex Qestions

Front 1

While ambulating with the nurse, the client begins to fall. the nurse should do which of the following to stabilize the client?
1. instruct the client to stand against the wall.
2. Lean the client forward while lowering the client to the floor.
3. Slide the client against the nurse's leg while lowering the client to the floor.
4. Use a narrow base of support.

Back 1

3.
To ensure safety of the client, the client's weight should be against the nurse's leg. The client would not have enough time to seek out a wall for support.
If leaned forward, the client moves away from the center of gravity.
-the nurse should establish a wide base of support.

Front 2

the nurse is positioning a client for a urinary catheterization. Which action would best prevent musculoskeletal injury to the nurse while performing this procedure?
1. narrowing the base of support.
2. positioning the client using a draw sheet.
3.raising the bed to a comfortable height.
4. using the nondominant hand to insert the catheter.

Back 2

3.
-Working with the bed at a comfortable height provides the proper position for the nurse to prevent musculoskeletal injury.
-nurse should use the dominant hand to insert the catheter to ensure better control and to avoid awkward postures.

Front 3

During the meal time, the nurse notices a client with his hands holding his throat area. Which situation would most require immediate action by the nurse?
1. the client has a high-pitched inspiratory stridor.
2.the client is coughing and talking.
3. the client is coughing only.
4.the client is not making any sounds.

Back 3

4.
-when the airway is totally blocked, the client is not able to make any sound. This requires immediate action.
-High pitched stridor indicates partially-blocked airway.
-if the client is talking or coughing , the airway is partially obstructed.

Front 4

The nurse must transfer a dependent client from a bed to a gurney. Which measure taken by the nurse will be safest for both the nurse and the client.
1. adjust the height of the client's bed.
2. Avoid movements that twist the spine.
3. keep the client close to her body when lifting.
4. Use a mechanical lift device appropriate for this client.

Back 4

4.
-The safest method for transferring this client is through use of mechanical lifting device. The other answers refer to use of body mechanics, which will not protect the nurse from injury or provide the safest transfer for the client.

Front 5

A Nurse is caring for a hospitalized client in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? Select all that APPLY?
1. Document restraint checks and patient status every two hours.
2. Educate the family about restraint use.
3.obtain the physician's order renewal every 72 hrs.
4.Provide 10 min. of release and repositioning.
5. Release the restraint and reposition the client every 4hrs.

Back 5

1, 2, 4
-restraint standard states that documentation must occur at least every 2hrs. It is important for the client's family to understand the purpose of the restraint. Orders are to be renewed q24hrs. when a restraint is used continuously. Release and repositioning should be provided for a minimum of 10 min. at least every 2hrs.

Front 6

The nurse is instructing the client about the prevention of carbon monoxide poisoning. Which of the following statements from the client indicates that more teaching is needed?
1. A high concentration of carbon monoxide can cause death.
2. I can detect the presence of carbon monoxide by a strong odor.
3. I can purchase a carbon Monoxide detector for my home.
4. I should inspect my carbon monoxide detector annually.

Back 6

2
-Carbon monoxide is odorless. all other options are correct.

Front 7

A nurse is preparing a presentation about bicycle safety for a health fair. For which target audience would this presentation be most appropriate?
1. Adolescents
2. Infants, toddlers, and preschool children
3. middle-aged adults
4. school-aged children

Back 7

4
-Bicycling-related injuries are major cause of injuries in school-aged children. Children 5-14 yrs. account for almost 1/3 of bicyclist deaths from traffic accidents. bicycle safety is not a primary risk at the other developmental stages.

Front 8

A nurse working the night shift is caring for a client who is at high risk for falls. Which of the following does the nurse need to consider when caring for this client? Select all that apply.
1. Keep the client's room dark by keeping the door closed.
2. Monitor the client at least every 4hrs. to ensure safety.
3. Move the client's room away from the nurse's station.
4. Place fall risk indicators ont eh client's door.
5. Teach the client to use the call light.
6. Turn off the client's bed alarm so the client is not disturbed.

Back 8

4, 5
-Fall risk indicators are used to alert staff of the client's fall risk statues. Teaching the client about the call light will help ensure the client has a way to call for assistance. Teh client should be placed near the nurses' station for close monitoring and response to client's needs. The purpose of the bed alarm is to alert the staff when the client gets out of bed

Front 9

A quadriplegic client is sliding down in bed. Which of the following is the best method to reposition this client?
1. One nurse lifting the client's leg while the client uses a trapeze.
2. Two nurses lifting the client under the shoulders.
3. Two nurses using a draw sheet.
4. Two nurses using a friction reducing device.

Back 9

4
-A friction reducing devise is the most effective method of moving the client up in bed. the client is not able to use the trapeze. Lifting the client under the shoulders places musculoskeletal strain on the nurse and could cause injury to the client's shoulders. A draw sheet does tlittle to reduce friction.

Front 10

The nurse looks into a client's room and notices a fire. What action should the nurse take first?
1. Activate the fire alarm.
2. Close all the doors.
3. Evacuate the client from the room.
4. Extinguish the fire.

Back 10

3
-In the event of a fire, first remove persons in the room. close the doors and windows and activate the alarm only after everyone is removed from the room. Extinguishing the fire would be the last step.