NCLEX : Prevention and Risk Management

Study concepts, example questions & explanations for NCLEX

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Example Questions

Example Question #1 : Prevention And Risk Management

A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
Possible Answers:
Ask the client if her daughter has ever been stung by a bee in the past
Instruct the client to keep the arm elevated until swelling goes away
Advise the client to bring her daughter to the emergency room
Tell the client to call back if the condition worsens
Correct answer: Tell the client to call back if the condition worsens
Explanation: The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.

Example Question #2 : Prevention And Risk Management

The nurse cares for an immobilized patient on the surgical floor. Which of the following nursing considerations is essential for preventing ulcerations?

Possible Answers:

Teach client the importance of coughing and deep breathing

Use compression stockings or TED hose

Providing a well-balanced diet

Orient client frequently

Frequently turn and reposition patient while also providing skin care

Correct answer:

Frequently turn and reposition patient while also providing skin care

Explanation:

There are many possible complications from immobilization. Decubitus ulcers are one of these complications. It is essential to turn and reposition the patient at least every 2 hours while also maintaining skin integrity with skin care. Many other complications may result from immobilization and each have specific, related nursing considerations. Immobilization can result in desensitization and disorientation, so it is important to orient the client frequently. A well-balanced diet can promote better nutrition to prevent osteoporosis, negative nitrogen balances, and hypercalcemia from being bed-bound. Compression stockings and TED hose are essential to prevent thrombus formation from stagnant blood flow in the lower extremities, which may lead to pulmonary emboli. Coughing and deep breathing is important to prevent the stasis of respiratory secretions, which could lead to hypostatic pneumonia.

Example Question #3 : Prevention And Risk Management

The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should __________.

Possible Answers:

wipe with mask with a clean towel

wait until the patient care is complete and replace the mask

exchange the mask for a new mask immediately

dry the mask with the in-room hairdryer

place a new mask over the old mask

Correct answer:

exchange the mask for a new mask immediately

Explanation:

Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately. 

Example Question #4 : Prevention And Risk Management

The nurse is preparing to enter a contact-isolation room where she will preform a bed bath. It is reasonable to expect her gloves to become soiled at some point during the administration of care. While preparing to enter, the nurse __________.

Possible Answers:

wears a pair of clean gloves under a pair of sterile gloves

wears a single pair of clean gloves

wears two pairs of sterile gloves

wears a single pair of sterile gloves

wears two pairs of clean gloves

Correct answer:

wears a single pair of clean gloves

Explanation:

In the interest of infection control, it is best to only wear one pair of gloves at a time. While giving a bed bath, it is not necessary to wear sterile gloves. If the gloves become saturated, remove the gloves, perform hand hygiene, and wear a new pair. 

Example Question #5 : Prevention And Risk Management

The emergency room nurse cares for a patient reporting pain in the lower back. The client tells the nurse, “I have taken three 500-milligram tablets of acetaminophen every three hours since last night, but the pain hasn’t gone away.” Which of the following clinical manifestations in the patient most concerns the nurse?

Possible Answers:

Ringing in the ears

alanine transaminase (ALT): 

Diarrhea and loose stools

Higher blood pressure

International normalized ratio (INR) of 1.1

Correct answer:

alanine transaminase (ALT): 

Explanation:

The nurse should be concerned about acetaminophen toxicity, as the recommended daily dose of acetaminophen is 4 grams for adults, and this patient has exceeded this amount. (Three 500-milligram tablets every three hours is equal to 12 grams in a 24-hour period.) Acetaminophen toxicity may manifest with nausea and vomiting in the first 24 hours and right upper quadrant abdominal pain afterwards due to liver damage. Tinnitus, high blood pressure, and diarrhea are not symptoms of acetaminophen poisoning. An international normalized ratio (INR) of 1.1 is within normal limits, but may be trending upwards, as the liver is responsible for producing clotting factors. Liver function tests should always be done when acetaminophen poisoning is suspected; aspartate transaminase (AST) and alanine transaminase (ALT) values above  suggest hepatic damage.

Example Question #6 : Prevention And Risk Management

The oncology nurse cares for a patient receiving morphine sulfate  IV push q4h for pain. Which of the following most concerns the nurse?

Possible Answers:

Respiratory rate 8 breaths per minute

Blood pressure

 

Oxygen saturation 98%

Pain level 7 out of 10

Heart rate 65 beats per minute

Correct answer:

Respiratory rate 8 breaths per minute

Explanation:

The nurse should be aware of potential complications of morphine sulfate, which can cause respiratory depression. Therefore, a respiratory rate of 8 breaths per minute should most concern the nurse (the normal limits are 12-18). The heart rate, blood pressure, and oxygen saturation are within normal limits. A patient on morphine sulfate should complain of pain, and although a pain level of 7 out of 10 requires attention, the respiratory depression takes priority.

Example Question #7 : Prevention And Risk Management

The nurse cares for a patient receiving an intravenous transfusion of gentamicin through an IV catheter in the patient’s left hand. Upon assessment, the nurse notices blanching and swelling at the site of the IV catheter, and the patient states he is feeling 8 out of 10 pain and it is “burning." In what order should the nurse perform the following tasks?

Possible Answers:

Discontinue the catheter, aspirate the remaining fluid, stop the infusion, and notify the primary care provider.

Stop the infusion, aspirate the remaining fluid, discontinue the catheter, and notify the primary care provider.

Notify the primary care provider, stop the infusion, aspirate the remaining fluid, and discontinue the catheter.

Aspirate the remaining fluid, stop the infusion, discontinue the catheter, and notify the primary care provider.

Stop the infusion, discontinue the catheter, notify the primary care provider, and aspirate the remaining fluid.

Correct answer:

Stop the infusion, aspirate the remaining fluid, discontinue the catheter, and notify the primary care provider.

Explanation:

The nurse must recognize these signs and symptoms as potential extravasation, where a vesicant medication such as gentamicin, penicillin, dilantin, or chemotherapy has been given. It is essential to first stop the infusion and remove the insult. The nurse must then aspirate the remaining medication in the catheter to reduce the amount of exposure to the vesicant. The nurse can then remove and discontinue the catheter and notify the primary care provider.

Example Question #8 : Prevention And Risk Management

The nurse counsels patients at a community health fair about the importance of immunizations. Which of the following statements is most accurate concerning immunizations?

Possible Answers:

“Immunizations will prevent all infectious diseases.”

“Immunizations are risk-free and recommended by all healthcare providers.”

“Immunizations provide natural immunity to some diseases.”

“Immunizations provide acquired immunity to some serious infectious diseases.”

“Immunizations give your body the antibodies to fight infections.”

Correct answer:

“Immunizations provide acquired immunity to some serious infectious diseases.”

Explanation:

The nurse should understand the mechanism of action, indications, and risks of immunizations as they do for all medications administered. Immunizations work by passively providing acquired immunity to specific diseases (such as influenza, hepatitis B, and varicella). They imitate a specific pathogen, influencing the patient’s body to produce antibodies that are capable of defending the body if it is exposed to the disease-causing element. The nurse should know that immunizations are specifically made for some diseases, and do not work for all diseases. Immunizations also come with minimal risks, and although they are widely given, are not universally prescribed. Patients should be educated with potential risks; some patients may experience fevers or rashes. Immunizations do not provide natural immunity to diseases; natural immunity is acquired by the patient when they contract a disease via exposure and the body produces its own antibodies. Immunizations do not provide antibodies to each disease.

Example Question #9 : Prevention And Risk Management

The community health nurse provides education about infectious diseases to college students in a dorm. Which of the following statements by the nurse would be appropriate?

Possible Answers:

“Hepatitis A is transmitted through infected blood and needles.”

“Hepatitis C is transmitted through ingestion of contaminated food and water.”

Hepatitis D is transmitted through ingestion of contaminated food and water.”

“Hepatitis B is transmitted through ingestion of contaminated food and water.”

“Hepatitis A is transmitted through ingestion of contaminated food and water.”

Correct answer:

“Hepatitis A is transmitted through ingestion of contaminated food and water.”

Explanation:

Different types of viral hepatitis are transmitted through various routes. Hepatitis A is the only form that is transmitted through the fecal-oral route (contaminated food and water). Hepatitis B and D are transmitted through infected blood/needles as well as sex, and from infected mothers to newborns. Hepatitis C is transmitted through contaminated blood and needles. Recall that hepatitis D is an opportunistic infection, which requires hepatitis B infection.

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