NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 601:

  How often must physical restraints be released?

  A. every 2 hours

  B. between 1 and 3 hours

  C. every 30 minutes

  D. at least every 4 hours

  Correct Answer: A

  Restraints must be released every 2 hours, and the client must be assessed every 30 minutes while restrained.

• Question 602:

  Attaching a restraint to a side rail or other movable part of the bed can __________.

  A. do nothing to the client

  B. injure the client if the rail or bed is moved

  C. help the client stay in the bed without falling out

  D. help the client with better posture

  Correct Answer: B

  Attaching a restraint to a movable part of the bed can cause client injury if that part of the bed is moved before releasing restraints.

• Question 603:

  Ethical and moral issues concerning restraints include all of the following except __________.

  A. emotional impact on the client and family

  B. dignity of the client

  C. client's quality of life

  D. policies and procedures

  Correct Answer: D

  Policies and procedures, though important, are not in the category of ethical and moral issues. The other options are ethical and moral issues.

• Question 604:

  In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers?

  A. Place extra padding under the mother to absorb blood from the delivery.

  B. Cut the umbilical cord using sterile scissors.

  C. Suction the baby's mouth and nose.

  D. Wrap the baby in a clean blanket to preserve warmth.

  Correct Answer: C

  After the baby delivers, the nurse should clear the mouth and nose of the infant first.

  Choice "Wrap the baby in a clean blanket to preserve warmth." is the next step.

  Choices "Place extra padding under the mother to absorb blood from the delivery." and "Cut the umbilical

  cord using sterile scissors." might be performed depending on the situation.

• Question 605:

  In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except __________.

  A. diabetic signs and symptoms

  B. nutritional status

  C. bleeding problems

  D. availability of insulin

  Correct Answer: C

  Bleeding problems are not characteristic of diabetes.

  All the other options are appropriate areas of assessment.

• Question 606:

  In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?

  A. ability to speak

  B. ability to hear

  C. oxygen saturation

  D. adventitious breath sounds

  Correct Answer: A

  Ability to speak is a major way to identify an airway obstruction.

• Question 607:

  Which isolation procedure will be followed for secretions and blood?

  A. Respiratory

  B. Standard Precautions

  C. Contact Isolation

  D. Droplet

  Correct Answer: B

  Standard precautions are taken in all situations for all clients and involve all body secretions except sweat and are designed to reduce the rate of transmission of microbes from one host to another or one source (environment such as the client's bedside table) to another.

• Question 608:

  The nurse is teaching a client about erythema infectiosum. Which of the following factors are not correct?

  A. There is no rash.

  B. The disorder is uncommon in adults.

  C. There is no fever.

  D. There is sometimes a "slapped face" appearance.

  Correct Answer: B

  Fifth's disease, erythema infectiosum, is uncommon in adults. All the other statements are correct.

• Question 609:

  The nurse is teaching a client about the use of Rifampin for prophylaxis after an exposure to meningitis. What change in bodily functions should the nurse advise the client about?

  A. The client's urine might turn blue.

  B. The client remains infectious to others for 48 hours.

  C. The client's contact lenses might be stained orange.

  D. The client's skin might take on a crimson glow.

  Correct Answer: C

  Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become

  permanently stained.

  Clients should be taught about these side effects to avoid unnecessary concern.

• Question 610:

  A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching.

  Which of the following advisory comments should be given?

  A. The history and presentation might indicate chickenpox, a highly contagious disease.

  B. The lesions might indicate a noncontagious infection that does not require isolation.

  C. The history and presentation might indicate an infectious illness called impetigo.

  D. The lesions are not contagious unless others have open wounds or lesions themselves.

  Correct Answer: C

  The scenario describes classic impetigo for which the physician is likely to order antibiotic therapy. Chickenpox is highly contagious but presents with a history of high fever followed by a vesicular rash.