NCLEX DEMO QUIZ

Question 1 of 6

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Which actions are appropriate to protect the client from injury? Select all that apply.

Attach wrist restraint straps to the upper side rails
Position the client supine to keep restraint straps taut
Release restraints at regular intervals and assess behavior
Use a square knot to tie restraint straps to the bed
Use gauze to pad bony prominences under restraints

Question 2 of 6

The client screams at the nurse, “You are all incompetent here! I have been waiting for 2 hours!” How should the nurse respond initially?

"I know you are upset, but I will have to call security if you continue to scream."
"I see that you are frustrated, but the delay cannot be avoided."
"It is upsetting to wait so long. How can I best help you?"
"The wait is long today, but you will receive quality, unhurried care when it is your turn."

Question 3 of 6

The nurse cares for a client who sustained a femur fracture twelve hours ago

Item 1 of 1

Nurses’ Notes
Client reports shortness of breath and stated, ‘something is not right.’ The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air. Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called.

Nurses’ Notes

Client reports shortness of breath and stated, ‘something is not right.’ The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air. Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called.

The client is demonstrating signs and symptoms consistent with which of the following conditions?

Pulmonary embolism
Myocardial infarction
Compartment syndrome
Fat embolism syndrome

Question 4 of 6

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?

Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor
Step in front of client, brace knees and feet against the client's, and assist to the floor gently
Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor
Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor

Question 5 of 6

The nurse enters a client’s room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse?

“Do you have any questions about the diagnosis?”
“There are medications available to treat Alzheimer disease.”
“This new diagnosis must be frightening for you.”
“We can help you make decisions about your care.”

Question 6 of 6

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit?

High-Fowler's position with the affected side's arm resting on the bed
Semi-Fowler's position with the affected side's arm on several pillows
Supine with the affected side's arm on several pillows
Supine with the affected side's arm resting on the bed

NCLEX DEMO QUIZ

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