A nurse is caring for a client who just underwent surgery. The client is experiencing dizziness and lightheadedness upon standing. The nurse suspects orthostatic hypotension. What action should the nurse prioritize? Multiple Choice Answers: A) Apply cold compresses to the client’s forehead. B) Assist the client in slowly changing positions. C) Administer an antihypertensive medication. D) Elevate the client’s legs above heart level. E) Encourage the client to stand quickly.
Correct Answer: B) Assist the client in slowly changing positions.
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Rationale: Orthostatic hypotension commonly occurs post-surgery due to fluid shifts. Teaching the client to change positions slowly helps prevent sudden drops in blood pressure, reducing the risk of falls or injuries. Applying cold compresses may provide comfort but doesn’t address the underlying cause. Administering antihypertensive medication or elevating the legs isn’t indicated for this condition. Encouraging the client to stand quickly could exacerbate symptoms.
A nurse is conducting an assessment on an elderly client admitted for dehydration. Which finding requires immediate intervention to ensure the client’s safety? Multiple Choice Answers: A) Dry oral mucous membranes. B) Decreased skin turgor. C) Low blood pressure. D) Decreased urine output. E) Mild confusion.
Correct Answer: E) Mild confusion.
Rationale: Mild confusion in an elderly client can indicate a severe underlying condition like electrolyte imbalances or dehydration, posing a risk for falls or accidents. Dry oral mucous membranes, decreased skin turgor, low blood pressure, and decreased urine output are indicators of dehydration but might not present immediate safety risks compared to altered mental status.
A nurse is caring for a client receiving enteral tube feedings. The nurse notes the feeding tube is clogged and there’s difficulty administering the prescribed formula. What action should the nurse take first? Multiple Choice Answers: A) Use warm water to flush the tube. B) Clamp the tubing and notify the healthcare provider. C) Add additional formula to force the clog out. D) Assess the client’s vital signs. E) Irrigate the tubing forcefully with saline.
Correct Answer: A) Use warm water to flush the tube.
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Rationale: Using warm water to flush the tube is a safe initial intervention to clear a clogged enteral feeding tube. Clamping the tubing and notifying the healthcare provider might be necessary but isn’t the first action. Adding more formula or forcefully irrigating the tube could worsen the clog or cause harm. Assessing vital signs is important but addressing the immediate issue of the clog takes precedence to ensure continued nutrition delivery.
NCLEX Review: Safety Treatments
These questions address key safety considerations in nursing practice, emphasizing the importance of timely interventions to ensure patient well-being and prevent potential harm.
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A nurse is preparing to administer medication to a client. The nurse checks the medication label three times but is unsure about the dosage accuracy. What action should the nurse take to ensure medication safety? Multiple Choice Answers: A) Administer the medication as prescribed. B) Consult with another nurse to verify the dosage. C) Ask the client about their previous medication doses. D) Delay the administration and recheck the prescription. E) Proceed to administer a lower dose than prescribed.
Correct Answer: D) Delay the administration and recheck the prescription.
Rationale: The nurse should prioritize patient safety by ensuring the accuracy of the medication dosage before administration. Double-checking the prescription and seeking clarification or verification from a colleague or supervisor is crucial to prevent medication errors. Administering the medication without certainty, altering the dosage without clarification, or solely relying on the client’s memory could compromise safety.
NCLEX Questions Critical Thinking: Safety Symptoms
1000 ANCC Questions
A nurse is caring for a postoperative client who is receiving oxygen therapy. The nurse observes the client smoking in the room. What action should the nurse take to address this safety concern? Multiple Choice Answers: A) Request the client’s family to remove smoking materials. B) Instruct the client to smoke near an open window. C) Advise the client to stop smoking during oxygen therapy. D) Provide a fire extinguisher nearby while the client smokes. E) Ignore the smoking behavior to avoid conflict.
Correct Answer: C) Advise the client to stop smoking during oxygen therapy.
Rationale: Smoking during oxygen therapy poses a significant fire hazard due to the highly flammable nature of oxygen. Advising the client to abstain from smoking while receiving oxygen reduces the risk of fire-related injuries. Other options such as relocating smoking materials, allowing smoking near a window, or ignoring the behavior do not directly address the safety concern and may further endanger the client.
NCLEX Focus Exploring Safety: Causes and Diagnosis
A nurse is conducting a fall risk assessment for an elderly client admitted with a history of falls. Which finding indicates an increased risk for falls in this client? Multiple Choice Answers: A) The client prefers to walk independently. B) The client wears non-slip footwear. C) The client has a history of dizziness upon standing. D) The client uses the call bell for assistance. E) The client requests to have a bedside commode.
Correct Answer: C) The client has a history of dizziness upon standing.
Rationale: A history of dizziness upon standing indicates orthostatic hypotension, which increases the risk of falls. While independence in walking, non-slip footwear, using a call bell for assistance, and requesting a bedside commode are positive safety measures, the history of dizziness suggests a physiological condition predisposing the client to falls.
A nurse is caring for a client with a nasogastric tube for feeding. The nurse notices the client coughing and struggling to breathe. What action should the nurse take first? Multiple Choice Answers: A) Notify the healthcare provider. B) Administer oxygen to the client. C) Remove the nasogastric tube immediately. D) Elevate the head of the client’s bed. E) Perform suctioning on the nasogastric tube.
Correct Answer: C) Remove the nasogastric tube immediately.
Rationale: The priority is to ensure the client’s airway is clear. Removing the nasogastric tube could alleviate the coughing and breathing difficulty. While notifying the healthcare provider, providing oxygen, elevating the client’s head, or performing suctioning might be necessary, immediate action to secure the airway takes precedence to prevent further compromise in breathing.
NCLEX Questions: Focus on Medications for Safety
A nurse is performing medication administration to a group of clients. One of the medications requires intramuscular injection. As the nurse prepares the injection, the client appears anxious and hesitant. What is the nurse’s initial action to ensure safe medication administration? Multiple Choice Answers: A) Proceed with the injection and reassure the client. B) Stop the procedure and ask the client about concerns. C) Call another nurse to administer the injection. D) Prepare the injection at a slower pace. E) Offer the client distraction techniques during the injection.
Correct Answer: B) Stop the procedure and ask the client about concerns.
Rationale: Ensuring patient safety includes addressing the client’s concerns and hesitations regarding the procedure. Stopping the process and actively engaging the client in a conversation can uncover fears or misconceptions, allowing the nurse to address them before proceeding. Continuing without clarification could escalate anxiety or lead to non-compliance.
1000 Medical-Surgical Questions
Understanding Safety: NCLEX Priority Questions
A nurse is caring for a client with impaired mobility. During the shift, the nurse notes a decrease in the client’s mobility and increased weakness. Which action should the nurse prioritize for the client’s safety? Multiple Choice Answers: A) Encourage the client to rest and avoid movement. B) Perform passive range of motion exercises. C) Use a lift device for transferring the client. D) Apply restraints to prevent falls. E) Document the changes in the client’s condition.
Correct Answer: C) Use a lift device for transferring the client.
Rationale: Using a lift device ensures the safety of both the client and the caregiver during transfers, especially when there’s a noted decrease in mobility and increased weakness. Encouraging rest or applying restraints can be counterproductive or compromise the client’s comfort and autonomy. Documenting changes in condition is important but doesn’t directly address the immediate safety concern.
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Understanding Safety: Causes and Symptoms
A nurse is teaching a group of parents about child safety measures at home. Which statement by a parent indicates a need for further teaching regarding safety precautions? Multiple Choice Answers: A) “We keep cleaning supplies locked in a cabinet.” B) “I always supervise my child around the pool.” C) “We allow our toddler to play unsupervised in the kitchen.” D) “We use safety gates at the top and bottom of the stairs.” E) “We cover electrical outlets with safety caps.”
Correct Answer: C) “We allow our toddler to play unsupervised in the kitchen.”
NCLEX Practice Questions: Understanding Safety Causes and Symptoms
Rationale: All statements except for allowing unsupervised play in the kitchen demonstrate awareness of safety measures. Allowing a toddler to play unsupervised in the kitchen poses various hazards, including access to sharp objects, hot surfaces, and potentially harmful substances. Teaching the importance of constant supervision in high-risk areas like the kitchen is crucial for child safety.