NCLEX review questions and material (NCSBN)Correct questions & Answers(GRADED A+)
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Course
NCLEX
Institution
NCLEX
How can you identify your patient? - ANSWERSName
Date of birth
MR number
NOT Room number
R.A.C.E - ANSWERSR: Remove and rescue patients
A: Activate fire alarm
C: Contain fire
E: Extinguish
Restraints - ANSWERSIf a client can easily remove the device, it does not qualify as a physi...
NCLEX review questions and material
(NCSBN)Correct questions &
Answers(GRADED A+)
How can you identify your patient? - ANSWERSName
Date of birth
MR number
NOT Room number
R.A.C.E - ANSWERSR: Remove and rescue patients
A: Activate fire alarm
C: Contain fire
E: Extinguish
Restraints - ANSWERSIf a client can easily remove the device, it does not qualify as a
physical restraint.
A provider order for restraints can never be written in advance for "what if" situations or
"as needed" (i.e., PRN).
Always attempt to use the least restrictive form of restraint and/or safety device. Never
apply or use a restraint (chemical, physical or seclusion) to punish a client
Chemical: These include medications such as anxiolytics, sedatives, opioids and
paralytics.
Physical: These include mechanical devices or equipment that limit the client from
moving or from moving an extremity. A chair with an attached tray that prevents the
client from getting up is considered a restraint. Raising all bed rails can be considered a
form of restraint; however, one raised side rail that the client uses to move in and out of
bed would not be considered a restraint.
Seclusion: A locked room or area away from other clients that the client cannot leave.
This is primarily used with clients in behavioral health settings who are at risk for violent
behavior and only after all other interventions have failed
A soft wrist restraint can be applied before a doctor's order is given, but the nurse must
contact the HCP immediately after the restraint is applied to obtain the order. (True or
False) - ANSWERSTrue
,Contact precautions - ANSWERSGastrointestinal infections, e.g., foodborne illness
such as norovirus or Clostridium difficile (C. diff.)
Diarrhea of unknown origin
Skin infections or infestations, e.g., impetigo, scabies
Presence of, or colonization with, multidrug-resistant bacteria, e.g. methicillin-resistant
Staphylococcus aureus (MRSA)
Gown, gloves, mask, eye protection
Herpes Zoster (shingles) disseminated needs what precautions - ANSWERSimplement
both contact and airborne precautions until lesions are dry and crusted.
Filing incidence report - ANSWERSMedication administration errors (even if the error
did not reach the client)
Any time a client makes a complaint
Medical device malfunction
Any time a client, staff member or visitor is injured or involved in a situation with the
potential for injury
When a client leaves the health care facility against medical advice (AMA)
Loss or theft of a client's or visitor's property
Immediate (red) - ANSWERSChest wounds
Shock
Open fractures
,2/3 degree burns
Delayed (yellow) - ANSWERSsecond priority
need treatment and transport but can be delayed
multiple injuries to bones or joints, back injuries
stable abd wounds
eye and CNS injury
Minimal (green) - ANSWERSMinor burns or fractures or bleeds
Expectant (black) - ANSWERSlast priority
dead or minimal chance of survival
cardiac arrest or open head injury
brain stem injury
chelating agents - ANSWERSmolecules that attract or bind with other molecules and
are therefore useful in either preventing or promoting movement of substances from
place to place
Potassium iodine: helps radioactive iodine in thyroid
Prussian blue : for cesium and thallium
Biological agents with a high probability of mass dissemination or person-to-person
transmission and high mortality rates include: - ANSWERSAnthrax (Bacillus anthracis)
Botulism (Clostridium botulinumtoxin)
Plague (Yersinia pestis)
Smallpox (Variola major)
The nurse is preparing to enter a disaster scene to assist with triaging victims. What
assessment priorities should the nurse adhere to? Select all that apply.
The nurse requires disaster certification before performing triage during a disaster.
The nurse should allocate resources to those victims with the strongest probability of
survival.
The nurse must consult a qualified health care provider prior to making client resource
decisions.
The nurse should assess clients by considering their airway, breathing, circulation and
neurological function.
, The nurse should consider the age of a victim before allocating any resources -
ANSWERSThe nurse should allocate resources to those victims with the strongest
probability of survival.
The nurse should assess clients by considering their airway, breathing, circulation and
neurological function.
The nurse is caring for a client with schizophrenia, who has an order for haloperidol 5
mg PO every four hours as needed. Which behaviors justify the use of this chemical
restraint? Select all that apply.
The client is crying after a difficult family meeting.
The client is refusing to participate in unit group activities.
The client is expressing paranoid delusions.
The client is verbalizing a plan to harm another client.
The client is experiencing command hallucinations. - ANSWERSThe client is expressing
paranoid delusions.
The client is verbalizing a plan to harm another client.
The client is experiencing command hallucinations.
Command hallucinations and paranoid delusions can be frightening or dangerous,
potentially causing a client to act aggressively. It is important to intervene before a client
acts on a plan to harm another person. An antipsychotic medication, such as
haloperidol, will help control and manage symptoms and behaviors associated with
schizophrenia. A chemical restraint should be used in an extreme or emergent situation.
A client has the right to refuse to participate in activities. Verbal intervention, such as
offering to speak with the client 1:1, would be appropriate if the client is upset and
crying.
Hyperbaric oxygen therapy increases the dissociation of - ANSWERScarbon monoxide
from the hemoglobin molecule.
Chelation therapy - ANSWERSis used for poisoning with mercury or lead.
Therapeutic hypothermia - ANSWERSis typically used after a cardiopulmonary arrest.
The nurse is caring for a client who is confused and has repeatedly attempted to pull out
their intravenous lines and feeding tube. The nurse receives an order from the health
care provider (HCP) to apply soft wrist restraints. Which actions by the nurse are
appropriate? Select all that apply.
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