NCLEX Safety
The nurse is performing an environmental assessment in the home of an older client. Which requires
immediate attention? - Unsecured scatter rugs
The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Which location
should the nurse select to administer the medication? - Vastus lateralis muscle
A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measure is
necessary when caring for this client? - Monitoring the skin around the stoma site for skin irritation
A client is having trouble remembering his prescribed medication regimen. Which statement by the
nurse is therapeutic? - "Let me go over your prescribed medications with you again."
A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed
linens changed. Which should the nurse wear to perform these tasks? - Gown and gloves
The nurse is collecting data from a client and is observing the client ambulate with the use of a cane.
For which client action, when observed, should the nurse intervene and suggest a physical therapy
referral? - The client moves the cane and the unaffected side together.
The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety
seats. Which information related to the safety of the infant is correct? - Restrain in a car seat in the
back seat in a semireclined, rear-facing position.
The nurse assists a health care provider with the insertion of a Miller-Abbott tube. After insertion of
the tube, the nurse should assist the client to which position? - On the right side
The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the
alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls
the pin on the fire extinguisher. Which is the next action the nurse should perform? - Aim at the base
of the fire.
The nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an
internal cervical (vaginal) radiation implant. Which action should the nurse suggest including in the
plan of care for the client? - Place a radiation sign on the door outside of the client's room.
, The nurse is inserting an indwelling urinary catheter into the urethra of a client. As the nurse inflates
the balloon, the client complains of discomfort. Which is the appropriate nursing action? - Aspirate
the fluid, advance the catheter further, and reinflate the balloon.
The nurse assists to conduct a home safety assessment with a client preparing for discharge, and the
client tells the nurse that a space heater is used to heat the apartment. Which instruction should the
nurse provide to the client regarding the use of the space heater? - The space heater needs to be
placed at least 3 feet from anything that can burn.
A client is being discharged to home following spinal fusion with insertion of rods. For which home
environment situation should the nurse suggest a consultation with the continuing care nurse? - The
bedroom and bath are on the second floor of the home.
The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The
nurse places which item on the seat of the chair as the best device for pressure relief? - Water pad
The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data
collection, the nurse notes that the client is severely dysphagic. The nurse should include which in
the plan of care? Select all that apply. - 1.
Allowing the client sufficient time to eat
2.
Providing oral hygiene after each meal
3.
Maintaining a suction machine at the bedside
The nurse is preparing to begin a continuous tube feeding on a client with a nasogastric tube. In
which position should the nurse place the client for safe administration of the tube feeding? - With
the head elevated 45 degrees
The nurse is instructed to complete a medication reconciliation form on a newly admitted client.
Why is it important for the nurse to ensure that this process is completed accurately? - It helps to
make sure that the health care provider is aware of all of the medications the client is taking and has
been taking at home.
The nurse is performing an environmental assessment in the home of an older client. Which requires
immediate attention? - Unsecured scatter rugs
The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Which location
should the nurse select to administer the medication? - Vastus lateralis muscle
A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measure is
necessary when caring for this client? - Monitoring the skin around the stoma site for skin irritation
A client is having trouble remembering his prescribed medication regimen. Which statement by the
nurse is therapeutic? - "Let me go over your prescribed medications with you again."
A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed
linens changed. Which should the nurse wear to perform these tasks? - Gown and gloves
The nurse is collecting data from a client and is observing the client ambulate with the use of a cane.
For which client action, when observed, should the nurse intervene and suggest a physical therapy
referral? - The client moves the cane and the unaffected side together.
The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety
seats. Which information related to the safety of the infant is correct? - Restrain in a car seat in the
back seat in a semireclined, rear-facing position.
The nurse assists a health care provider with the insertion of a Miller-Abbott tube. After insertion of
the tube, the nurse should assist the client to which position? - On the right side
The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the
alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls
the pin on the fire extinguisher. Which is the next action the nurse should perform? - Aim at the base
of the fire.
The nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an
internal cervical (vaginal) radiation implant. Which action should the nurse suggest including in the
plan of care for the client? - Place a radiation sign on the door outside of the client's room.
, The nurse is inserting an indwelling urinary catheter into the urethra of a client. As the nurse inflates
the balloon, the client complains of discomfort. Which is the appropriate nursing action? - Aspirate
the fluid, advance the catheter further, and reinflate the balloon.
The nurse assists to conduct a home safety assessment with a client preparing for discharge, and the
client tells the nurse that a space heater is used to heat the apartment. Which instruction should the
nurse provide to the client regarding the use of the space heater? - The space heater needs to be
placed at least 3 feet from anything that can burn.
A client is being discharged to home following spinal fusion with insertion of rods. For which home
environment situation should the nurse suggest a consultation with the continuing care nurse? - The
bedroom and bath are on the second floor of the home.
The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The
nurse places which item on the seat of the chair as the best device for pressure relief? - Water pad
The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data
collection, the nurse notes that the client is severely dysphagic. The nurse should include which in
the plan of care? Select all that apply. - 1.
Allowing the client sufficient time to eat
2.
Providing oral hygiene after each meal
3.
Maintaining a suction machine at the bedside
The nurse is preparing to begin a continuous tube feeding on a client with a nasogastric tube. In
which position should the nurse place the client for safe administration of the tube feeding? - With
the head elevated 45 degrees
The nurse is instructed to complete a medication reconciliation form on a newly admitted client.
Why is it important for the nurse to ensure that this process is completed accurately? - It helps to
make sure that the health care provider is aware of all of the medications the client is taking and has
been taking at home.
