Saunders NCLEX SAFETY Q&A 2023 A+

Saunders NCLEX SAFETY Q&A 2023 A+ The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply. - ANS-Wearing gloves when emptying the client's bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the client's room Wearing a lead apron when providing direct care to the client The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply. - ANS-Explain the procedure to the client. Irrigate the NG tube with saline. Elevate the head of the bed to 45 degrees. The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply. - ANS-Time the start and stop of the seizure. Apply oxygen at 2L with nasal cannula. Turn the client to the side and do not restrain. Note the distinguishing characteristics of the seizure. Turn on the suction machine with oral catheter. The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply. - ANS-Use a friction-reducing slide sheet. Use a mechanical lift to move the client. Keep elbows close and work close to the body. Obtain assistance of a second caregiver to assist with mechanical aids. A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)? - ANS-A bottle of alcohol A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic? - ANS-"Let me go over your prescribed medications with you again." The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply. - ANS-Homeopathy Herbal supplements The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions should the nurse take? Select all that apply. - ANS-Place the client flat in bed. Notify the registered nurse of the drainage. A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply. - ANSMonitoring the skin around the stoma site for skin irritation Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention should the nurse institute next for the client? - ANS-Wrap a light roll of gauze to cover the IV site. The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action? - ANSActivate the fire alarm The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply. - ANS-Pedal pulses Capillary refill Color of the extremity Temperature of the skin Presence of numbness 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-Alternating air pad The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action? - ANS-Reset the degrees of flexion or extension according to comfort. The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply. - ANS-Eat a nutritious diet with adequate protein. Use a pressure relief pad while in a wheelchair. Check the bottom sheet for wetness and wrinkles. The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply. Continues...