a nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace what should the nurse do to safeguard the clients neckl a nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace what should the nurse do to safeguard the clients neckl
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Nursing Elites

NCLEX NCLEX-PN

Nclex PN Questions and Answers

1. While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace?

Correct answer: Ask the client for permission to lock the necklace in the hospital safe

Rationale: When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.

2. The nursing assistant hitting the client in the long-term care facility can be charged with:

Correct answer: Assault

Rationale: Assault is the appropriate charge in this scenario. Assault involves physically striking or touching someone inappropriately. Negligence (Choice A) refers to failing to provide proper care for the client. Tort (Choice B) is a wrongful act committed against the client or their property. Malpractice (Choice D) is the failure to perform an act that should have been done or the improper performance of an act resulting in harm to the client. Since the nursing assistant physically struck the client, the charge of assault is most fitting.

3. What is the most common cause of acute renal failure?

Correct answer: A

Rationale: The correct answer is 'Shock.' Acute renal failure is commonly caused by inadequate blood flow to the kidneys, which can occur in cases of shock. This leads to decreased kidney function and potential kidney damage. While nephrotoxic drugs can also cause acute renal failure, shock is the primary and most common cause. An enlarged prostate may lead to obstructive uropathy but is not the most prevalent cause of acute renal failure. Diabetes is typically associated with chronic kidney disease rather than acute renal failure.

4. The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?

Correct answer: Covering the affected leg with a blanket to avoid chills

Rationale: The correct answer is to intervene when the assistant covers the affected leg with a blanket to avoid chills. A new cast should not be covered to allow the heat from the cast to evaporate, preventing complications. Lifting the affected leg with the palms of the hands is appropriate for proper handling. Placing plastic over the groin prior to bathing is a standard practice to protect the client's privacy and maintain hygiene. Elevating the casted leg on two pillows helps reduce swelling and promote circulation, making it a suitable action.

5. What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?

Correct answer: Explore the interaction with the patient care assistant

Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.

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