NCLEX safety Questions with Verified
Answers
A client is transferred from the emergency department to the locked psychiatric unit
after attempting suicide by taking 200 acetaminophen tablets. The client is now awake
and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is
to: - ANSWERSensure safety by initiating suicide precautions
A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation,
incoherent speech, agitation, frantic and aimless physical activity, and grandiose
delusion. Which nursing diagnosis takes highest priority for this client at this time? -
ANSWERSrisk for injury
What should the nurse teach the parent of a 3-year-old child with eczema to remove
from the child's environment at home? - ANSWERSstuffed animals; For the child with
eczema, which is commonly related to an allergic response, stuffed animals should be
avoided because they tend to collect dust and are difficult to clean
When caring for the client with hepatitis B, which situation would expose the nurse to
the virus? - ANSWERSa blood splash into the nurse's eyes; Hepatitis B virus is spread
through contact with blood, body fluids contaminated with blood, and such body fluids
as cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions.
The risk of transmission of hepatitis B through feces is low. Touching the client without
gloves is acceptable when there is no danger of contact with blood or body fluids.
Recapping a used needle is a common source of needlestick injuries; needles should
be properly disposed of uncapped.
A client has received numerous different antibiotics and now is experiencing diarrhea.
What type of precautions should the nurse institute? - ANSWERScontact precautions;
The nurse should initiate contact precautions to prevent blood borne infection through
percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp
objects are handled. Airborne precautions are required for clients with presumed or
proven pulmonary tuberculosis, chickenpox, or other airborne pathogens. Contact
precautions are used for organisms that are spread by skin-to-skin contact, such as
antibiotic-resistant organisms or Clostridium difficile. Droplet precautions are used for
organisms such as influenza or Neisseria meningitides that can be transmitted by close
respiratory or mucous membrane contact with respiratory secretions. Standard
precautions include handwashing and use of a mask and gown.
The children of an elderly client who has suffered an ischemic stroke have informed the
nurse that an herbalist will be coming to their parent's bedside tomorrow to make
recommendations for client's care. Which considerations should the nurse prioritize in
, light of the practitioner's planned visit? - ANSWERSensuring any complementary
therapies are safe when combined with his prescribed therapy
A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation,
and incoherence of speech with frantic and aimless physical activity and grandiose
delusions. Which would the highest priority goal in planning nursing interventions? -
ANSWERSThe client will show no self-harm or harm to staff.
The nurse assists the client to the operating room table and supervises the operating
room technician preparing the sterile field. Which action, completed by the surgical
technician, indicates to the nurse that a sterile field has been contaminated? -
ANSWERSWetness in the sterile cloth on top of the nonsterile table has been noted;
Moisture outside the sterile package contaminates the sterile field because fluid can be
wicked into the sterile field. Bacteria tend to settle, so there is less contamination above
waist level and away from the technician. The outer inch of the drape is considered
contaminated but does not indicate that the sterile field itself has been contaminated.
A parent calls the health clinic and tells the nurse that the toddler was found with an
open and empty bottle of acetaminophen. The parent asks the nurse what to do. What
is the nurse's priority intervention? - ANSWERSGive the parent instructions on how to
call poison control;
A biohazardous trash container is placed outside of a client's room. Which item should
the nurse place in this container? Select all that apply. - ANSWERSliquid blood
semiliquid blood
dressing with blood
dressing with purulent drainage
To prepare the community for the possible threat of anthrax, a nurse must teach that -
ANSWERSanthrax can infect the integumentary, GI, and respiratory systems; Penicillin
is the most common drug used to threat anthrax. Immunizations are appropriate only for
those at risk of anthrax exposure.
A nurse discovers that a hospitalized client with stage 4 esophageal cancer and major
depression has a gun in the home. What is the best nursing intervention to help the
client remain safe after discharge? - ANSWERSTalk with the health care provider
(HCP) about requiring gun removal as a condition of discharge.
Which action by the nursing assistant would require immediate intervention by the
nurse? - ANSWERSrestraining a school-age child at risk for self-harm because the
nursing assistant had to leave the room
The nurse notices that a cart being used to transport a client has a nonfunctioning clasp
on the safety belt. What should the nurse do next? - ANSWERSRequest that the
transporter bring a different cart with a functional clasp.
Answers
A client is transferred from the emergency department to the locked psychiatric unit
after attempting suicide by taking 200 acetaminophen tablets. The client is now awake
and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is
to: - ANSWERSensure safety by initiating suicide precautions
A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation,
incoherent speech, agitation, frantic and aimless physical activity, and grandiose
delusion. Which nursing diagnosis takes highest priority for this client at this time? -
ANSWERSrisk for injury
What should the nurse teach the parent of a 3-year-old child with eczema to remove
from the child's environment at home? - ANSWERSstuffed animals; For the child with
eczema, which is commonly related to an allergic response, stuffed animals should be
avoided because they tend to collect dust and are difficult to clean
When caring for the client with hepatitis B, which situation would expose the nurse to
the virus? - ANSWERSa blood splash into the nurse's eyes; Hepatitis B virus is spread
through contact with blood, body fluids contaminated with blood, and such body fluids
as cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions.
The risk of transmission of hepatitis B through feces is low. Touching the client without
gloves is acceptable when there is no danger of contact with blood or body fluids.
Recapping a used needle is a common source of needlestick injuries; needles should
be properly disposed of uncapped.
A client has received numerous different antibiotics and now is experiencing diarrhea.
What type of precautions should the nurse institute? - ANSWERScontact precautions;
The nurse should initiate contact precautions to prevent blood borne infection through
percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp
objects are handled. Airborne precautions are required for clients with presumed or
proven pulmonary tuberculosis, chickenpox, or other airborne pathogens. Contact
precautions are used for organisms that are spread by skin-to-skin contact, such as
antibiotic-resistant organisms or Clostridium difficile. Droplet precautions are used for
organisms such as influenza or Neisseria meningitides that can be transmitted by close
respiratory or mucous membrane contact with respiratory secretions. Standard
precautions include handwashing and use of a mask and gown.
The children of an elderly client who has suffered an ischemic stroke have informed the
nurse that an herbalist will be coming to their parent's bedside tomorrow to make
recommendations for client's care. Which considerations should the nurse prioritize in
, light of the practitioner's planned visit? - ANSWERSensuring any complementary
therapies are safe when combined with his prescribed therapy
A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation,
and incoherence of speech with frantic and aimless physical activity and grandiose
delusions. Which would the highest priority goal in planning nursing interventions? -
ANSWERSThe client will show no self-harm or harm to staff.
The nurse assists the client to the operating room table and supervises the operating
room technician preparing the sterile field. Which action, completed by the surgical
technician, indicates to the nurse that a sterile field has been contaminated? -
ANSWERSWetness in the sterile cloth on top of the nonsterile table has been noted;
Moisture outside the sterile package contaminates the sterile field because fluid can be
wicked into the sterile field. Bacteria tend to settle, so there is less contamination above
waist level and away from the technician. The outer inch of the drape is considered
contaminated but does not indicate that the sterile field itself has been contaminated.
A parent calls the health clinic and tells the nurse that the toddler was found with an
open and empty bottle of acetaminophen. The parent asks the nurse what to do. What
is the nurse's priority intervention? - ANSWERSGive the parent instructions on how to
call poison control;
A biohazardous trash container is placed outside of a client's room. Which item should
the nurse place in this container? Select all that apply. - ANSWERSliquid blood
semiliquid blood
dressing with blood
dressing with purulent drainage
To prepare the community for the possible threat of anthrax, a nurse must teach that -
ANSWERSanthrax can infect the integumentary, GI, and respiratory systems; Penicillin
is the most common drug used to threat anthrax. Immunizations are appropriate only for
those at risk of anthrax exposure.
A nurse discovers that a hospitalized client with stage 4 esophageal cancer and major
depression has a gun in the home. What is the best nursing intervention to help the
client remain safe after discharge? - ANSWERSTalk with the health care provider
(HCP) about requiring gun removal as a condition of discharge.
Which action by the nursing assistant would require immediate intervention by the
nurse? - ANSWERSrestraining a school-age child at risk for self-harm because the
nursing assistant had to leave the room
The nurse notices that a cart being used to transport a client has a nonfunctioning clasp
on the safety belt. What should the nurse do next? - ANSWERSRequest that the
transporter bring a different cart with a functional clasp.
