PN
PN NCLEX EVOLVE: S AFETY QUESTIONS
AND ANSWERS UPDATED (2024/2025)
(VERIFIED ANSWERS)
The nurse is caring for a client who becomes agitated and begins to pull on
a surgically placed abdominal drainage tube. The health care provider
visits and prescribes restraints if needed. Which action is appropriate to
delegate to the unlicensed assistive personnel (UAP), who has completed
the facility's education about care of the restrained client? Select all that
apply. - ANS ✓Socialize with the restrained client.
Remove the restraint and perform range of motion activity
Reapply the restraint after assisting the client to the bathroom
Rationale:
The skill of applying restraints can be delegated to the UAP whom the nurse
knows is competent in caring for a client with restraints. The nurse is
responsible to document the mental status of the client necessitating the
restraints. The nurse must determine the appropriate type of restraint and
frequency of position change. The UAP may perform care including meeting
mobility, hydration, nutrition, elimination, and socialization needs and
removing and reapplying restraints under the direction of the nurse.
The nurse is working in a long-term care facility and is observing a new
unlicensed assistive personnel (UAP) caring for a client who requires a
security device (wrist restraints). The nurse determines that the nursing
assistant is providing safe care if the nurse observes the UAP checking skin
integrity by completely removing the client's wrist restraints at which time
interval? - ANS ✓Every 2 hours
1
PN NCLEX
, PN
Rationale:
Restraints should be completely removed for a brief period at least every 2
hours, and this action should be documented in the nurse's notes. The color
of the extremity should be noted, and the pulse should be assessed. The
client should be asked to move the extremity, or range-of-motion exercises
should be performed. Agency guidelines regarding the use of restraints
should always be followed.
A client with chronic pain has been taught how to operate a transcutaneous
electrical nerve stimulation (TENS) unit. Which action by the client shows
understanding of the appropriate use of the device when the level of
stimulation is uncomfortable? - ANS ✓The client adjust the setting downward
slightly.
Rationale:
The client applies a transcutaneous electrical nerve stimulation unit by
placing two electrodes on the skin and adjusting the level of stimulation to
one lead at a time. The amount of stimulation is increased until the client
feels discomfort, which indicates that the maximal stimulation necessary to
block painful stimuli has been reached. The volume is then reduced slightly
until no further discomfort occurs. The other options are incorrect.
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? - ANS ✓Water pad
Rationale:
The client who cannot independently shift weight should have a pressure
relief pad in place under the buttocks to prevent skin breakdown. The best
products for use in providing pressure relief are those that equalize the
client's weight on the device. These include foam, water, gel, or alternating
air pads. A plastic-lined pad absorbs moisture but provides no pressure
relief. A pillow provides cushion but does not redistribute weight equally.
An air ring relieves pressure in some spots but causes pressure in others by
its design.
2
PN NCLEX
PN NCLEX EVOLVE: S AFETY QUESTIONS
AND ANSWERS UPDATED (2024/2025)
(VERIFIED ANSWERS)
The nurse is caring for a client who becomes agitated and begins to pull on
a surgically placed abdominal drainage tube. The health care provider
visits and prescribes restraints if needed. Which action is appropriate to
delegate to the unlicensed assistive personnel (UAP), who has completed
the facility's education about care of the restrained client? Select all that
apply. - ANS ✓Socialize with the restrained client.
Remove the restraint and perform range of motion activity
Reapply the restraint after assisting the client to the bathroom
Rationale:
The skill of applying restraints can be delegated to the UAP whom the nurse
knows is competent in caring for a client with restraints. The nurse is
responsible to document the mental status of the client necessitating the
restraints. The nurse must determine the appropriate type of restraint and
frequency of position change. The UAP may perform care including meeting
mobility, hydration, nutrition, elimination, and socialization needs and
removing and reapplying restraints under the direction of the nurse.
The nurse is working in a long-term care facility and is observing a new
unlicensed assistive personnel (UAP) caring for a client who requires a
security device (wrist restraints). The nurse determines that the nursing
assistant is providing safe care if the nurse observes the UAP checking skin
integrity by completely removing the client's wrist restraints at which time
interval? - ANS ✓Every 2 hours
1
PN NCLEX
, PN
Rationale:
Restraints should be completely removed for a brief period at least every 2
hours, and this action should be documented in the nurse's notes. The color
of the extremity should be noted, and the pulse should be assessed. The
client should be asked to move the extremity, or range-of-motion exercises
should be performed. Agency guidelines regarding the use of restraints
should always be followed.
A client with chronic pain has been taught how to operate a transcutaneous
electrical nerve stimulation (TENS) unit. Which action by the client shows
understanding of the appropriate use of the device when the level of
stimulation is uncomfortable? - ANS ✓The client adjust the setting downward
slightly.
Rationale:
The client applies a transcutaneous electrical nerve stimulation unit by
placing two electrodes on the skin and adjusting the level of stimulation to
one lead at a time. The amount of stimulation is increased until the client
feels discomfort, which indicates that the maximal stimulation necessary to
block painful stimuli has been reached. The volume is then reduced slightly
until no further discomfort occurs. The other options are incorrect.
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? - ANS ✓Water pad
Rationale:
The client who cannot independently shift weight should have a pressure
relief pad in place under the buttocks to prevent skin breakdown. The best
products for use in providing pressure relief are those that equalize the
client's weight on the device. These include foam, water, gel, or alternating
air pads. A plastic-lined pad absorbs moisture but provides no pressure
relief. A pillow provides cushion but does not redistribute weight equally.
An air ring relieves pressure in some spots but causes pressure in others by
its design.
2
PN NCLEX
