safety nclex questions and Answers Graded A

safety nclex questions and Answers Graded A a 3-year old child is admitted to the pediatric unit. which should the nurse do to maintain the safety of this preschool-age child? a. teach the child how to use the call bell b. put the child in a crib with high side rails c. ensure the child is under continuous supervision d. have the child stay in the playroom most of the day - ANS- c. ensure the child is under continuous supervision a client brings several electronic devices to a nursing home. one of the devices has a two-pronged plug. which rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug? a. controls stray electrical currents b. promotes efficient use of electricity c. shuts off the appliance if there is an electrical surge d. divides the electricity among the appliances in the room - ANS- a. controls stray electrical currents a client has dysphagia. which nursing action takes priority when feeding this client? a. ensuring that dentures are in place b. medicating for pain before providing meals c. providing verbal cueing to swallow each bite d. checking the mouth for emptying between every bite meals - ANS- d. checking the mouth for emptying between every bite a family member brings an electronic radio to a client in a long-term care facility. the client tells the nurse that an electric shock was felt while turning on the radio. which should the nurse do first? a. arrange for the maintenance department to examine the radio b. disconnect the radio from the source of energy c. check the client's skin for electrical burns d. take the client's apical pulse - ANS- d. take the client's apical pulse a home-care nurse is assigned to care for an older adult living at home. which is the first action the home-care nurse should employ to prevent falls by this older adult? a. conduct a comprehensive risk assessment b. encourage the client to remove throw rugs in the home c. suggest installation of adequate lighting throughout the home d. discuss with the client the expected changes of aging that place one at risk - ANS- a. conduct a comprehensive risk assessment a male client is admitted to ambulatory care for a bilateral heniorrhaphy. a nurse on the unit interviews the client, obtains the client's vital signs , and reviews the primary health-care provider's prescriptions. which should the nurse do first? a. contact the operating suite and inform them of the client's latex allergy b. ensure the client's allergy band includes the client's identified allergies c. notify the primary health-care provider of the client's elevated vital signs d. share the information about the client's anxiety with health team members - ANS- b. ensure the client's allergy band includes the client's identified allergies a nurse educator is teaching a group of newly hired nursing assistants. which hospitalized client should they be taught is at the highest risk for injury? a. school-age child b. comatose teenager c. postmenopausal woman d. confused middle-age man - ANS- d. confused middle-age man a nurse identifies he presence of smoke exiting the door to the dirty utility room. place the nurse's actions in order of priority using the RACE model. a. pull the fire alarm b. close unit doors and windows c. shut the door to the utility room d. provide emotional support to the agitated clients - ANS- a. pull the fire alarm c. shut the door to the utility room b. close unit doors and windows d. provide emotional support to the agitated clients a nurse in the nursing education department of a community hospital is planning an inservice education class about injury prevention. which factor that most commonly causes physical injuries in hospitalized clients should be included in the teaching plan? a. malfunctioning equipment b. failure to use restraints c. visitors d. falls - ANS- d. falls a nurse is assessing a client who is being admitted to the hospital. which is the most important information that indicates whether the client is at risk for physical injury? a. weakness experienced during a prior admission b. medication that increases intestinal motility c. two recent falls that occurred at home d. the need for corrective eyeglasses - ANS- c. two recent falls that occurred at home a nurse is caring for a client with a nasogastric tube for gastric decompression. which nursing action takes priority? a. discontinuing the wall suction when providing nursing care b. positioning the client in the semi-fowler position c. instilling the tube with 30 mL of air every 2 hours d. caring for the nares at least every 8 hours - ANS- b. positioning the client in the semi-fowler position a nurse is caring for a client with dementia. which time of day is of most concern for the nurse when trying to protect this client from injury? a. afternoon b. morning c. evening d. night - ANS- d. night a nurse is caring for a confused client. which should the nurse do to prevent this client from falling? a. encourage the client to use the corridor handrails b. place the client in a room near the nurses' station c. reinforce how to use the call bell d. maintain close supervision - ANS- d. maintain close supervision a nurse is caring for a patient with parkinson's disease who is experiencing difficulty swallowing. for which major potential problem associated with dysphagia should the nurse assess the client? a. anorexia b. aspiration c. self-care deficit d. inadequate intake - ANS- b. aspiration a nurse is orienting a newly admitted client to the hospital. which is most important for the nurse to teach the client how to do? a. notify the nurse when help is needed b. get out of the bed to use the bathroom c. raise and lower the head and foot of the bed d. use the telephone system to call family members - ANS- a. notify the nurse when help is needed a nurse is planing care for a client with a wrist restraint. how often should a restraint be removed, the area massaged, and the joints moved through their full range? a. once a shift b. once an hour c. every 2 hours d. every 4 hours - ANS- c. every 2 hours a nurse is planning care for a client who requires bilateral arm restraints because the client is delirious and attempting to pull out a urinary retention catheter. which information is important to consider when planning care for this client? (select all that apply) a. use of restraints adequately prevents injuries b. reasons for use of restraints must be clearly documented c. most clients recognize that restraints contribute to their safety d. restraints need a health-care provider's prescription before application e. laws permit the use of restraints when specific guidelines are followed - ANS- b. reasons for use of restraints must be clearly documented e. laws permit the use of restraints when specific guidelines are followed a nurse is preparing a bed to receive a newly admitted client to the hospital. which action is most important? a. placing the client's name on the end of the bed b. ensuring that the bed wheels are locked c. positioning the call bell in reach d. raising one side rail - ANS- b. ensuring the bed wheels are locked a nurse is preparing a client for a physical examination. which is most important for the nurse to do in this situation? a. identify the positions contraindicated for the client during the examination b. explore the client's attitude toward health-care providers c. inquire about other professionals caring for the client d. ask when the client last had a physical examination - ANS- a. identify the positions contraindicated for the client during the examination a nurse must apply a hospital gown that does not have snaps on the shoulders to a client receiving an iv infusion in the forearm. which should the nurse do? a. put the gown on the client's arm without the iv, drape the gown over the other shoulder, and adjust the closure behind the neck b. close the clamp on the iv tubing for no more than 15 seconds while putting the gown on the client c. disconnect the client's iv at the insertion site, apply the gown, and then reconnect the iv d. insert the client's iv bag and tubing through the sleeve from inside of the gown first - ANS- d. insert the client's iv bag and tubing through the sleeve from inside the gown first a nurse uses the get up and go test to assess a client for weakness, poor balance, and decreased flexibility. place the following actions in the order in which they should be implemented when employing the get up and go test. a. ask the client to walk 10 feet and then to return to the chair b. ask the client to close the eyes c. ask the client to open the eyes d. ask the client to sit in a chair e. ask the client to stand - ANS- d. ask the client to sit in a chair e. ask the client to stand b. ask the client to close the eyes c. ask the client to open the eyes a. ask the client to walk 10 feet and then return to the chair