NCLEX Safety Exam 90 Questions with Correct Answers.
A client is transferred from the emergency department to the locked psychiatric unit after
attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert
but refuses to speak with the nurse. In this situation, the nurse's first priority is to: - ✔✔✔
ensure safety by initiating suicide precautions
A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation,
incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion.
Which nursing diagnosis takes highest priority for this client at this time? - ✔✔✔ risk for
injury
What should the nurse teach the parent of a 3-year-old child with eczema to remove from
the child's environment at home? - ✔✔✔ stuffed animals; For the child with eczema, which
is commonly related to an allergic response, stuffed animals should be avoided because
they tend to collect dust and are difficult to clean
When caring for the client with hepatitis B, which situation would expose the nurse to the
virus? - ✔✔✔ a blood splash into the nurse's eyes; Hepatitis B virus is spread through
contact with blood, body fluids contaminated with blood, and such body fluids as
cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions. The
risk of transmission of hepatitis B through feces is low. Touching the client without gloves is
acceptable when there is no danger of contact with blood or body fluids. Recapping a used
needle is a common source of needlestick injuries; needles should be properly disposed of
uncapped.
A client has received numerous different antibiotics and now is experiencing diarrhea.
What type of precautions should the nurse institute? - ✔✔✔ contact precautions; The
nurse should initiate contact precautions to prevent blood borne infection through
percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp
objects are handled. Airborne precautions are required for clients with presumed or proven
pulmonary tuberculosis, chickenpox, or other airborne pathogens. Contact precautions
are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant
organisms or Clostridium difficile. Droplet precautions are used for organisms such as
influenza or Neisseria meningitides that can be transmitted by close respiratory or mucous
membrane contact with respiratory secretions. Standard precautions include
handwashing and use of a mask and gown.
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? - ✔✔✔ 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? - ✔✔✔ 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? - ✔✔✔ 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? - ✔✔✔ 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. - ✔✔✔ 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 -
✔✔✔ 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? - ✔✔✔ Talk with the health care provider (HCP) about
requiring gun removal as a condition of discharge.
Which action by the nursing assistant would require immediate intervention by the nurse? -
✔✔✔ 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? - ✔✔✔ Request that the transporter bring a
different cart with a functional clasp.
A client is transferred from the emergency department to the locked psychiatric unit after
attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert
but refuses to speak with the nurse. In this situation, the nurse's first priority is to: - ✔✔✔
ensure safety by initiating suicide precautions
A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation,
incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion.
Which nursing diagnosis takes highest priority for this client at this time? - ✔✔✔ risk for
injury
What should the nurse teach the parent of a 3-year-old child with eczema to remove from
the child's environment at home? - ✔✔✔ stuffed animals; For the child with eczema, which
is commonly related to an allergic response, stuffed animals should be avoided because
they tend to collect dust and are difficult to clean
When caring for the client with hepatitis B, which situation would expose the nurse to the
virus? - ✔✔✔ a blood splash into the nurse's eyes; Hepatitis B virus is spread through
contact with blood, body fluids contaminated with blood, and such body fluids as
cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions. The
risk of transmission of hepatitis B through feces is low. Touching the client without gloves is
acceptable when there is no danger of contact with blood or body fluids. Recapping a used
needle is a common source of needlestick injuries; needles should be properly disposed of
uncapped.
A client has received numerous different antibiotics and now is experiencing diarrhea.
What type of precautions should the nurse institute? - ✔✔✔ contact precautions; The
nurse should initiate contact precautions to prevent blood borne infection through
percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp
objects are handled. Airborne precautions are required for clients with presumed or proven
pulmonary tuberculosis, chickenpox, or other airborne pathogens. Contact precautions
are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant
organisms or Clostridium difficile. Droplet precautions are used for organisms such as
influenza or Neisseria meningitides that can be transmitted by close respiratory or mucous
membrane contact with respiratory secretions. Standard precautions include
handwashing and use of a mask and gown.
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? - ✔✔✔ 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? - ✔✔✔ 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? - ✔✔✔ 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? - ✔✔✔ 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. - ✔✔✔ 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 -
✔✔✔ 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? - ✔✔✔ Talk with the health care provider (HCP) about
requiring gun removal as a condition of discharge.
Which action by the nursing assistant would require immediate intervention by the nurse? -
✔✔✔ 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? - ✔✔✔ Request that the transporter bring a
different cart with a functional clasp.
