you are turning your patient in bed and you see that this confused and lethargic patient had loose car keys and lipstick in the bed and had been lying
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Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. You are turning your patient in bed and notice that a confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for due to all three of these factors: confusion, lethargy, and items in the bed?

Correct answer: B

Rationale: This patient is at great risk for skin breakdown due to the presence of three specific risk factors: confusion, lethargy, and items in the bed. While confusion puts the patient at risk for falls, confusion and lethargy together may lead to a lack of mobility. However, skin breakdown is the primary concern in this scenario as it is associated with all three risk factors - confusion, lethargy, and the presence of items in the bed. Therefore, the correct answer is 'Skin breakdown'.

2. When escorting a patient to the operating room on a stretcher, what should you do to prevent the patient from falling?

Correct answer: B

Rationale: When escorting a patient to the operating room on a stretcher, it is crucial to secure a safety belt or strap on the patient to prevent falls during the transfer. This safety measure is not considered a restraint but a necessary precaution. Lowering the bed position is not necessary; in fact, the bed should be in a high position to align with the stretcher. Locking the wheels of the stretcher is essential to prevent accidents during patient transfer. Therefore, the correct action to prevent falls while moving a patient to the operating room is to use a safety belt or strap on the patient throughout the escort.

3. Which of the following is an example of libel?

Correct answer: B

Rationale: Libel involves making defamatory statements against another person in written form. These statements can harm the person's reputation or feelings. In this scenario, the correct answer is when a client reads disparaging remarks that a nurse has written about him in his chart. This constitutes libel because the negative remarks are written down and can potentially damage the client's reputation. Choices A, C, and D do not involve libel. Choice A describes a verbal statement, not written, so it does not constitute libel. Choice C involves a failure to notify a physician, which is a different issue unrelated to libel. Choice D pertains to administering medication without an order, which is a matter of improper practice rather than libel.

4. A client on lithium has diarrhea and vomiting. What should the nurse do first?

Correct answer: D

Rationale: Diarrhea and vomiting are manifestations of lithium toxicity. The priority action for the nurse is to hold the next dose of lithium and obtain an order for a stat serum lithium level to confirm toxicity. This ensures patient safety and prevents further harm. Recognizing it as a drug interaction is not the first step in this scenario. Cogentin is used to manage extrapyramidal symptoms (EPS) associated with antipsychotics, not lithium toxicity. Reassuring the client about these symptoms as common side effects of lithium therapy is inappropriate as they indicate a more serious issue than typical side effects like hand tremors, nausea, polyuria, and polydipsia.

5. When a nurse is asked by a physician to speak to a colleague about their unprofessional behavior in front of a client but chooses not to confront the colleague and avoids the physician the next day, what type of conflict resolution is the nurse exhibiting?

Correct answer: C

Rationale: The nurse is exhibiting the conflict resolution strategy of avoidance. Avoidance involves ignoring the problem in the hope that it will go away on its own. In this scenario, the nurse avoids confronting the colleague and stays away from the physician, which does not address the issue directly. While avoidance may provide time for others to gain insight into the situation, it typically does not lead to a resolution of the underlying problems. Accommodation (A) involves yielding to the wishes of others, competition (B) entails pursuing one's own concerns at the expense of others, and negotiation (D) involves seeking a mutually agreeable solution through communication and compromise, none of which are demonstrated by the nurse in this situation.

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