NCLEX SAFETY EXAM STUDY GUIDE WITH
QUESTIONS AND VERIFIED ANSWERS.
GRADED A+. 2024/2025 UPDATE.
NEW!!! NEW!!! NEW!!!
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? - ANS✔✔-
ensuring 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? - ANS✔✔-The 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? - ANS✔✔-Wetness 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? - ANS✔✔-Give 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. - ANS✔✔-liquid
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 - ANS✔✔-anthrax 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? - ANS✔✔-Talk with the health care
provider (HCP) about requiring gun removal as a condition of discharge.
A nurse on a night shift entered an elderly client's room during a scheduled
check and discovered the client on the floor beside the bed after falling when
trying to ambulate to the washroom. After assessing and assisting the client
back to bed, the nurse has completed an incident report. What is the primary
purpose of this particular type of documentation? - ANS✔✔-identifying risks and
ensuring future safety for clients
Which variables should the nurse judge as likely to indicate high risk when
assessing a client's potential for suicide? Select all that apply. - ANS✔✔-age 60
and older
living alone
previous suicide attempts
financial distress;
Risk factors for completed suicide are hopelessness, medical illness, severe
anhedonia (loss of ability to feel pleasure), male gender, Caucasian or Native
American/First Nations ethnoracial background, living alone, age 60 or older,
unemployment, financial distress, or previous suicide attempt. Anger is a low-
risk factor for suicide.
, The nurse is teaching a client how to self-administer epinephrine using an EpiPen
autoinjector. What information should be included in the teaching? Select all that
apply. - ANS✔✔-After administering the injection, massage the area for 10
seconds.
Hold the EpiPen autoinjector against the thigh for 10 seconds.
Jab the EpiPen autoinjector firmly into the outer thigh.
The nurse received an order to administer intravenous fluids with potassium for
a client receiving intravenous fluids. What step(s) are included in the process?
Select all that apply. - ANS✔✔-Review the client's laboratory values.
Obtain correct ordered intravenous fluids.
Identify client with two methods.
Review the label of the intravenous tubing.
The nurse is planning care for a toddler with a seizure disorder. Which item in
the care plan should the nurse revise? - ANS✔✔-The nurse should revise a care
plan that includes padded tongue blades. Nothing should be placed in the mouth
during a seizure. Padded side rails will protect the child from injury during a
seizure. The bag and mask system should be present in case the child needs
oxygen during a seizure. Most seizures resolve in under 5 minutes. If they do
not, then a dose of lorazapam can be administered. The healthcare provider will
prescribe the correct dosage for weight and the parameters for administering.
The nurse administers an antipsychotic drug to a client with acute mania. The
client still refuses to lie down on her bed, pushes other clients in the hallways,
and screams threatening remarks to the staff. What should the nurse do next? -
ANS✔✔-Seclude the client and use restraints if necessary.
Which action by the nursing assistant would require immediate intervention by
the nurse? - ANS✔✔-restraining 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? -
ANS✔✔-Request that the transporter bring a different cart with a functional
clasp.
QUESTIONS AND VERIFIED ANSWERS.
GRADED A+. 2024/2025 UPDATE.
NEW!!! NEW!!! NEW!!!
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? - ANS✔✔-
ensuring 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? - ANS✔✔-The 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? - ANS✔✔-Wetness 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? - ANS✔✔-Give 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. - ANS✔✔-liquid
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 - ANS✔✔-anthrax 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? - ANS✔✔-Talk with the health care
provider (HCP) about requiring gun removal as a condition of discharge.
A nurse on a night shift entered an elderly client's room during a scheduled
check and discovered the client on the floor beside the bed after falling when
trying to ambulate to the washroom. After assessing and assisting the client
back to bed, the nurse has completed an incident report. What is the primary
purpose of this particular type of documentation? - ANS✔✔-identifying risks and
ensuring future safety for clients
Which variables should the nurse judge as likely to indicate high risk when
assessing a client's potential for suicide? Select all that apply. - ANS✔✔-age 60
and older
living alone
previous suicide attempts
financial distress;
Risk factors for completed suicide are hopelessness, medical illness, severe
anhedonia (loss of ability to feel pleasure), male gender, Caucasian or Native
American/First Nations ethnoracial background, living alone, age 60 or older,
unemployment, financial distress, or previous suicide attempt. Anger is a low-
risk factor for suicide.
, The nurse is teaching a client how to self-administer epinephrine using an EpiPen
autoinjector. What information should be included in the teaching? Select all that
apply. - ANS✔✔-After administering the injection, massage the area for 10
seconds.
Hold the EpiPen autoinjector against the thigh for 10 seconds.
Jab the EpiPen autoinjector firmly into the outer thigh.
The nurse received an order to administer intravenous fluids with potassium for
a client receiving intravenous fluids. What step(s) are included in the process?
Select all that apply. - ANS✔✔-Review the client's laboratory values.
Obtain correct ordered intravenous fluids.
Identify client with two methods.
Review the label of the intravenous tubing.
The nurse is planning care for a toddler with a seizure disorder. Which item in
the care plan should the nurse revise? - ANS✔✔-The nurse should revise a care
plan that includes padded tongue blades. Nothing should be placed in the mouth
during a seizure. Padded side rails will protect the child from injury during a
seizure. The bag and mask system should be present in case the child needs
oxygen during a seizure. Most seizures resolve in under 5 minutes. If they do
not, then a dose of lorazapam can be administered. The healthcare provider will
prescribe the correct dosage for weight and the parameters for administering.
The nurse administers an antipsychotic drug to a client with acute mania. The
client still refuses to lie down on her bed, pushes other clients in the hallways,
and screams threatening remarks to the staff. What should the nurse do next? -
ANS✔✔-Seclude the client and use restraints if necessary.
Which action by the nursing assistant would require immediate intervention by
the nurse? - ANS✔✔-restraining 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? -
ANS✔✔-Request that the transporter bring a different cart with a functional
clasp.
