NCSBN NCLEX Review 2022/2023

A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse? 1. "I need you to go to the waiting area. You can come back when you're more in control." 2. "I'm going to give you a few minutes alone so you can calm down." 3 "I can't think when you are yelling at me. Talk to me in a normal voice." 4. "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." - ANSWER "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." Most violent behavior is preceded by warning signs, such as yelling or swearing. The challenge for nurses is to apply interventions that de-escalate a person's response to stressful or traumatic events. The keys to effective limit setting are using commands to express the desired behavior and providing logical and enforceable consequences for noncompliance. Nurses should acknowledge the agitated person's feelings and be empathetic, reminding him or her that they are there to help. The clinic nurse assists the health care provider with physical examinations and the collection of laboratory specimens. Which of these findings does the nurse recognize as being reportable to the public health department? Positive eye discharge confirming conjunctivitis Clinical findings of impetigo Skin scraping confirming the presence of ringworm Positive stool culture for shigella - ANSWER Positive stool culture for shigella The Centers for Disease Control and Prevention (CDC) have a list of notifiable infectious diseases that is updated yearly. Shigellosis is the only reportable infection of those listed. Shigella are bacteria that can infect the digestive tract and cause (painful) diarrhea, cramping, vomiting, nausea; in severe cases it can cause seizures and kidney failure. Ringworm is a contagious fungal infection. Impetigo is a contagious, superficial bacterial skin infection. Conjunctivitis has many causes and is usually diagnosed from signs and symptoms and patient history. Mass casualty survivors are brought to the emergency department (ED) after a disaster. The nurse is assigned to four clients who were triaged in the field and have just arrived in the ED. Which client will the nurse care for first? The person with multiple wounds and an open fracture The person with hypotension and a sucking chest wound The person with head trauma requiring mechanical ventilation The person with an undisplaced fracture of the radius - ANSWER Typically, the tab colors used in triage are black, yellow, green and red. Red-tagged clients have immediate threats to life and require care right away; this would be the survivor with hypotension and a sucking chest wound. Yellow-tagged clients have major injuries that need treatment within 30 minutes to two hours (the client with the open fracture), and green-tagged client have injuries that can be delayed more than two hours (the closed fracture). Black-tagged clients are treated last during a mass casualty situation because there is little chance for survival. A parent calls the hospital hotline and is connected to the triage nurse. The caller states: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would provide the best information to help the nurse to determine if the child has swallowed a corrosive substance? "Ask the child if the mouth is burning or throat pain is present." "Has the child had vomiting, diarrhea or stomach cramps?" "Take the child's pulse at the wrist and see if the child has trouble breathing lying flat." "What color are the child's lips and nails and has the child voided today?" - ANSWER "Ask the child if the mouth is burning or throat pain is present." Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful in determining the child's overall condition. However, the question concerns evaluation for ingestion of a caustic substance. The nurse is checking on clients in the unit. Which of these findings indicates that an infusion pump set to deliver a morphine drip basal rate of 10 mL per hour, plus PRN dosages for breakthrough pain, is not functioning correctly? The client states: "I just can't get relief from my pain." The level of the drug is 100 mL at 9 am and is 50 mL at 12 noon The level of the drug is 100 mL at 8 am and is 80 mL at 12 noon The client complains of discomfort at the IV insertion site - ANSWER The level of the drug is 100 mL at 8 am and is 80 mL at 12 noon The minimal dose is 10 mL per hour, which would mean 40 mL is given in a four-hour period. If any PRN doses were given then less would be in the bag. Minimally, 60 mL should be left at 1200 (12 Noon). The pump is not functioning when more than expected medicine is left in the container. A client with hepatitis A (HAV) is newly admitted to the unit. Which action(s) would be the priority to include immediately in the plan of care? (Select all that apply) Implement standard precautions Implement contact precautions Implement low calorie low fiber diet Implement a vaccine protocol Implement teaching on improved sanitation - ANSWER Implement standard precautions Implement contact precautions Hepatitis A is transmitted though the ingestion of fecal matter, even in microscopic amounts, from close person-to-person contact and sexual contact with an infected person. Additionally, HAC can be transmitted through the ingestion of contaminated food or drinks. Implementation of standard and contact precautions are priority actions a nurse would implement upon admission for the protection of healthcare staff and visitors. Clients with Hepatitis A require a diet that is low in fat (fat is metabolized in the liver) but high in calories, carbohydrates and protein. The client should also eliminate all alcoholic beverages. Vaccine recommendations and breaking the chain of infection through improved sanitation is a teaching responsibility that will be addressed by the nurse before the client's discharge and will include the client and family/friends. The client, who is diagnosed with dementia, wanders throughout the long-term care facility. How can the nurse best ensure the safety of a client who wanders? Attach a monitoring band to the client's wrist Explain the risk of walking with no purpose Frequently reorient the client to time, person and place Apply a restraint to keep keep the client in a chair when awake - ANSWER Attach a monitoring band to the client's wrist A wander management system is used to give people with dementia and other "at risk" clients the ability to move freely where they live. The sensor in the bracelet trips an alarm that's attached to exterior doors if the client attempts to leave the facility. It is inappropriate to use restraints or other restrictive devices to keep clients in chairs or beds (unless they are potentially harmful to themselves or others.) Reality orientation is inappropriate for someone with dementia. The client is observed falling out of bed when reaching for something on the overbed table. The client then states: "Don't just stand there. I feel fine - help me up." What is the correct order of actions the nurse should take? Complete an incident report Assist the client back to bed, with the help from other staff Call the health care provider Obtain a complete set of vital signs - ANSWER Obtain a complete set of vital signs Assist the client back to bed, with the help from other staff Call the health care provider Complete an incident report The first step is always to assess the client for any obvious injuries and to obtain a complete set of vital signs (especially blood pressure) and neurologic assessments. If the client does not appear to be injured, staff members can assist the client back into bed. The nurse should then call the health care provider to report the incident. Finally, the nurse should complete the incident report. Of course, personal items should be placed close to the client so that they can reach them. The nurse listens to report about a newly admitted client who has a skin ulcer that's tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions must be taken for this hospitalized client? (Select all that apply.) Keep all equipment in the client's room for his/her sole use Place the client in a single room Wear mask when providing routine care to the client Perform hand hygiene after direct contact with the client and before leaving the room Keep the door to the room closed, with a notice for visitors - ANSWER Keep all equipment in the client's room for his/her sole use Place the client in a single room Perform hand hygiene after direct contact with the client and before leaving the room Keep the door to the room closed, with a notice for visitors Contact precautions are recommended in acute care settings for MRSA when there's a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room, with the door closed; the sign on the door instructs visitors to report to the nurse before entering the room. All equipment, such as stethoscopes and blood pressure devices, should be for the client's sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and his/her environment and before leaving the isolation room. Contact precautions require health care workers to wear gloves and a gown; a face mask is not necessary for routine care. What is the acronym to remember when there is a fire? - ANSWER RACE Remove/Rescue clients Activate fire alarm system Contain the fire (Close all doors and windows) Extinguish flames (With fire extinguisher)