NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 581:

  Which of the following statements describes the purpose of client restraint?

  A. Restraints are a nursing measure used to maintain client control.

  B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.

  C. Restraints are a therapeutic measure designed to positively reinforce client behavior.

  D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

  Correct Answer: B

  The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician's order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider.

• Question 582:

  What does client and family communication and education concerning restraints do?

  A. confuses both groups more

  B. helps with coping and stress levels

  C. encourages cooperation with the client and family

  D. puts the responsibility on the client and family, not the nurse

  Correct Answer: C

  Cooperation is more likely if the client and family understand the purpose of and expected gains from

  restraints.

  Well-meaning family members might release restraints if their purpose is not clear.

• Question 583:

  Padding on a restraint helps __________.

  A. with pressure distribution so that bony prominences do not receive pressure when a client pulls against the restraints

  B. the client feels more secure

  C. to keep infection and wounds down

  D. to keep restraints in place

  Correct Answer: A

  Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client

  pulls against the restraints.

  Pressure, especially over bony prominences, causes tissue damage due to ischemia.

• Question 584:

  All of the following are causes of vaginal bleeding in late pregnancy except __________.

  A. placenta previa

  B. eclampsia

  C. abruptio placentae

  D. uterine rupture

  Correct Answer: B

  Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This

  condition can cause seizure and/or coma. Placenta previa and abruptio placentae are abnormal conditions

  that can cause bleeding, particularly in the third trimester.

  Uterine rupture is a major obstetrical emergency that can cause bleeding internally and externally.

• Question 585:

  All of the following clients are in need of an emergency assessment except __________.

  A. a bleeding client who has an injury from falling debris

  B. an unresponsive client

  C. a client with an old injury

  D. a pregnant woman with imminent delivery

  Correct Answer: C

  The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.

• Question 586:

  In a disaster, triage situation, the nurse should be least concerned with which of the following regarding a client in crisis?

  A. ability to breathe

  B. pallor or cyanosis of the skin

  C. number of accompanying family members

  D. motor function

  Correct Answer: C

  The least important factor (of those listed) during an emergency situation is the number of accompanying family members.

• Question 587:

  The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase.

  Which type is it?

  A. hepatitis A

  B. hepatitis B

  C. hepatitis C

  D. hepatitis D

  Correct Answer: A

  Hepatitis A does not produce a carrier state.

  It is transmitted via contaminated water or food via the oral-fecal route and is not blood borne.

• Question 588:

  A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information.

  The nurse knows that another name for the disorder is __________.

  A. Kawasaki disease.

  B. rheumatic disease.

  C. lupus erythematosus.

  D. fifth disease.

  Correct Answer: D

  The child has Fifth disease, a parvovirus flulike illness that is self-limiting but is contagious for two-three weeks.

• Question 589:

  A stool culture reveals Shigella.

  What corollary should the nurse recognize regarding this bacterial infection?

  A. People who have been in contact with the client need to be tested.

  B. Shigella is an airborne infection.

  C. Shigella is a bacteria sometimes found in stagnant water.

  D. The nurse should wear a one-way breathing apparatus when giving client care.

  Correct Answer: C

  Shigella is a bacteria sometimes found in stagnant water.

  Transmission of Shigella is typically oral-fecal, so good hand washing and the use of gloves are the best

  means of prevention when caring for a client with Shigella.

  The bacteria can be found in food and water contaminated by fecal material.

  Incidences of Shigella are reportable in many states.

• Question 590:

  Which of the following clients require airborne precautions?

  A. a client with fever, chills, vomiting, and diarrhea

  B. a client suspected of varicella (chickenpox)

  C. a client with abdominal pain and purpura

  D. a client diagnosed with AIDS

  Correct Answer: B

  Chickenpox (varicella) is an acute, infectious, airborne illness that requires others in direct contact to wear a respirator mask.