NCLEX review questions and material (NCSBN) practice exam questions and answers

How can you identify your patient? Name Date of birth MR number NOT Room number R.A.C.E R: Remove and rescue patients A: Activate fire alarm C: Contain fire E: Extinguish Restraints If a client can easily remove the device, it does not qualify as a physical restraint. A provider order for restraints can never be written in advance for "what if" situations or "as needed" (i.e., PRN). Always attempt to use the least restrictive form of restraint and/or safety device. Never apply or use a restraint (chemical, physical or seclusion) to punish a client Chemical: These include medications such as anxiolytics, sedatives, opioids and paralytics. Physical: These include mechanical devices or equipment that limit the client from moving or from moving an extremity. A chair with an attached tray that prevents the client from getting up is considered a restraint. Raising all bed rails can be considered a form of restraint; however, one raised side rail that the client uses to move in and out of bed would not be considered a restraint. Seclusion: A locked room or area away from other clients that the client cannot leave. This is primarily used with clients in behavioral health settings who are at risk for violent behavior and only after all other interventions have failed A soft wrist restraint can be applied before a doctor's order is given, but the nurse must contact the HCP immediately after the restraint is applied to obtain the order. (True or False) True Contact precautions Gastrointestinal infections, e.g., foodborne illness such as norovirus or Clostridium difficile (C. diff.) Diarrhea of unknown origin Skin infections or infestations, e.g., impetigo, scabies Presence of, or colonization with, multidrug-resistant bacteria, e.g. methicillin-resistant Staphylococcus aureus (MRSA) Gown, gloves, mask, eye protection Herpes Zoster (shingles) disseminated needs what precautions implement both contact and airborne precautions until lesions are dry and crusted. Droplet precautions Influenza Meningococcal meningitis Mumps Rubella (German measles) Diphtheria Pertussis (Whooping cough) Infections caused by drug-resistant Streptococcus pneumonia Surgical mask 6 ft distance gown and gloves when providing care Airborne precautions Varicella (chicken pox) Tuberculosis Measles (rubella) N95 Filing incidence report Medication administration errors (even if the error did not reach the client) Any time a client makes a complaint Medical device malfunction Any time a client, staff member or visitor is injured or involved in a situation with the potential for injury When a client leaves the health care facility against medical advice (AMA) Loss or theft of a client's or visitor's property Triage Categories Immediate, Delayed, Minimal, Expectant Immediate (red) Chest wounds Shock Open fractures 2/3 degree burns Delayed (yellow) second priority need treatment and transport but can be delayed multiple injuries to bones or joints, back injuries stable abd wounds eye and CNS injury Minimal (green) Minor burns or fractures or bleeds Expectant (black) last priority dead or minimal chance of survival cardiac arrest or open head injury brain stem injury chelating agents molecules that attract or bind with other molecules and are therefore useful in either preventing or promoting movement of substances from place to place Potassium iodine: helps radioactive iodine in thyroid Prussian blue : for cesium and thallium Biological agents with a high probability of mass dissemination or person-to-person transmission and high mortality rates include: Anthrax (Bacillus anthracis) Botulism (Clostridium botulinumtoxin) Plague (Yersinia pestis) Smallpox (Variola major) The nurse is preparing to enter a disaster scene to assist with triaging victims. What assessment priorities should the nurse adhere to? Select all that apply. The nurse requires disaster certification before performing triage during a disaster. The nurse should allocate resources to those victims with the strongest probability of survival. The nurse must consult a qualified health care provider prior to making client resource decisions. The nurse should assess clients by considering their airway, breathing, circulation and neurological function. The nurse should consider the age of a victim before allocating any resources The nurse should allocate resources to those victims with the strongest probability of survival. The nurse should assess clients by considering their airway, breathing, circulation and neurological function. The nurse is caring for a client with schizophrenia, who has an order for haloperidol 5 mg PO every four hours as needed. Which behaviors justify the use of this chemical restraint? Select all that apply. The client is crying after a difficult family meeting. The client is refusing to participate in unit group activities. The client is expressing paranoid delusions. The client is verbalizing a plan to harm another client. The client is experiencing command hallucinations. The client is expressing paranoid delusions. The client is verbalizing a plan to harm another client. The client is experiencing command hallucinations. Command hallucinations and paranoid delusions can be frightening or dangerous, potentially causing a client to act aggressively. It is important to intervene before a client acts on a plan to harm another person. An antipsychotic medication, such as haloperidol, will help control and manage symptoms and behaviors associated with schizophrenia. A chemical restraint should be used in an extreme or emergent situation. A client has the right to refuse to participate in activities. Verbal intervention, such as offering to speak with the client 1:1, would be appropriate if the client is upset and crying. Hyperbaric oxygen therapy increases the dissociation of carbon monoxide from the hemoglobin molecule. Chelation therapy is used for poisoning with mercury or lead. Therapeutic hypothermia is typically used after a cardiopulmonary arrest. The nurse is caring for a client who is confused and has repeatedly attempted to pull out their intravenous lines and feeding tube. The nurse receives an order from the health care provider (HCP) to apply soft wrist restraints. Which actions by the nurse are appropriate? Select all that apply. Conduct a thorough physical assessment of the client. Tie the wrist restraints using quick-release knots. Explain the rationale for the use of restraints to the client. Call the HCP every 48 hours for a new restraint order. Release the restraints and provide care every four hours. Document that alternative interventions were attempted. Conduct a thorough physical assessment of the client. Tie the wrist restraints using quick-release knots. Explain the rationale for the use of restraints to the client. Document that alternative interventions were attempted Restraints should only be used as a last resort. If necessary, the least restrictive device should be used to restrain a client. Situations that require the use of restraints include when clients interfere with treatment (e.g., enteral feedings, intravenous infusions, etc.). Every two hours, restraints must be removed to assess skin integrity, allow for range of motion and assess neurovascular status. Even though the client may be confused, the nurse must still explain the reason for applying restraints. Wrist restraints should be tied to a stationary part of the bed with a quick-release knot. A new restraint order must be written by the HCP every 24 hours. Prior to applying restraints, the nurse must conduct a thorough assessment of the client and document the events leading to the use of the restraint. The nurse should also document which alternatives to restraints were tried and the client's response to those measures The nurse is caring for a client diagnosed with gastroenteritis, caused by a Salmonella infection. Which intervention should the nurse implement to prevent transmission of this infection? Isolate the client in a single room without a roommate. Wear two pairs of gloves when changing linens. Wash hands with soap and water after client contact. Place the client on contact precautions. Wash hands with soap and water after client contact. Salmonella is a bacteria and one of the primary causes of foodborne illnesses such as gastroenteritis. Bacteria transmission usually occurs through ingestion of the organisms via contaminated foods and the oral-fecal route. The Centers for Disease Control and Prevention (CDC) recommends using standard precautions for this infection; therefore, the best way to prevent spread of the infection is to perform handwashing before and after client contact, using soap and water The nurse is providing discharge education to a client hospitalized for an acute exacerbation of rheumatoid arthritis. The nurse includes information focusing on conserving energy. Which statements by the client demonstrate the teaching has been effective? Select all that apply. "I will sit on a tall kitchen stool instead of standing when I am preparing meals." "On days of increased pain, I will stay in bed and relax instead of being active." "I will set priorities and complete the important tasks first." "I will schedule activities throughout the day instead of trying to complete everything in the morning." "If possible, I will delegate some things to my friends or family." "I will sit on a tall kitchen stool instead of standing when I am preparing meals." "I will set priorities and complete the important tasks first." "I will schedule activities throughout the day instead of trying to complete everything in the morning." "If possible, I will delegate some things to my friends or family." Rheumatoid arthritis is a chronic, systemic, progressive autoimmune disease involving the joints. As the disease progresses, the client's joints will become increasingly inflamed and painful. An important topic to teach these clients focuses on maintaining consistent activity and energy conservation. Regular exercise is essential for clients with arthritis to prevent complications. The client should be as active as possible and not be immobile on days of increased pain. Regarding energy conservation, important concepts include pacing, prioritizing and delegating activity. The client should rest when possible. During a routine visit, the nurse is evaluating developmental milestones for a 7-month-old child. Which of these developmental activities should the child be able to perform? Drinks from a cup Sits leaning on hands for support Says several words Uses a neat pincer grasp Sits leaning on hands for support The nurse enters a toddler's hospital room to administer an oral medication. When the nurse asks the child, "Are you ready to take your medicine?" the child's response is an immediate, "No!" Which action would be appropriate by the nurse? Ask another nurse to hold the child while giving the medication. Leave the room and return five minutes later to try to give the medication. Explain to the child that the medicine must be taken now. Notify the health care provider and request a parenteral form of the medication. Leave the room and return five minutes later to try to give the medication. During toddlerhood, a child will begin to display negativism. This negativism is an effort to develop a sense of control and autonomy. By asking the child if they were ready to take the medication, the