NCLEX RN Practice Test

The correct action is to assess for further signs of complications such as redness, tenderness, or purulent discharge, stop any infusions, and notify the healthcare provider about potential complications like an infection or thrombosis. Swelling and discomfort at the CVC site can be early indicators of significant issues, such as a central line-associated bloodstream infection (CLABSI) or catheter-related thrombosis. Prompt intervention is critical to prevent serious outcomes like sepsis or complete catheter occlusion. Flushing the line, waiting for symptoms to resolve, or applying compresses still delays necessary intervention and can exacerbate underlying complications.

The statement is accurate because non-verbal behaviors like pacing, avoiding interaction, and tense posture are commonly associated with psychological distress. However, these behaviors are not definitive by themselves and should be assessed alongside other factors such as client history and verbal communication. If a nurse observes these non-verbal cues, it is important to perform a more comprehensive assessment to determine the underlying cause and provide appropriate care.

This statement is false. While verbal orders may be necessary during emergencies, nursing practice requires that the order be documented as soon as the situation stabilizes. Proper documentation ensures accountability, reduces the risk of errors, and supports legal and professional standards. Failing to document the verbal order violates protocols and could compromise client safety.

The correct answer is to report any suspected abuse to the appropriate authorities because healthcare providers are mandated reporters. Mandated reporting laws require that healthcare professionals report cases of suspected child abuse to protect the client from harm and ensure they receive necessary interventions. It is not within the nurse's scope of practice to investigate or confirm abuse, as this is the responsibility of child protective services or law enforcement. Documenting observations and notifying the healthcare provider are essential but do not fulfill the legal duty to report.

The correct answer demonstrates culturally responsive care by collaborating with a dietitian to ensure that the client’s vegetarian diet and nutritional needs are met during recovery while respecting their cultural practices. Coordinating care with a dietitian ensures adherence to the client’s values without compromising their health. The other options are incorrect because discouraging fasting or promoting the standard menu fails to align with the client's cultural values and preferences. Providing general dietary education without addressing the cultural component does not sufficiently address the client’s personalized requirements.

The correct answer is to discard the syringe in a designated sharps container and place the soiled bandages in a biohazard bag. Sharps containers are used to prevent needle-stick injuries and reduce the risk of contamination. Biohazard bags are designed specifically to handle infectious or biohazardous waste, ensuring it is disposed of according to safety guidelines. Wrapping soiled bandages in a paper towel does not meet proper disposal standards, and rinsing biohazardous materials is not appropriate as it may lead to environmental contamination. Double bagging non-labeled trash bags does not meet regulatory requirements for identifying the waste as hazardous or biohazardous.

The correct answer involves encouraging the client to share more about their feelings and experiences. Reflective listening and open-ended questions are essential components of therapeutic communication as they convey empathy and understanding while facilitating the client's self-expression. The other answers either redirect the focus away from the client’s emotions or fail to encourage further communication, which can hinder the therapeutic relationship.

Lochia progresses through three stages postpartum: lochia rubra (red and bloody, lasting 3-4 days), lochia serosa (pinkish-brown, lasting up to 10 days), and lochia alba (whitish-yellow, lasting 2-6 weeks). Lochia that remains red after four days may indicate complications such as retained placenta or delayed uterine involution. It is important for nurses to educate clients on the expected timeline to help them identify any abnormalities. Incorrect answers may include signs of infection, which are unrelated to the timeline of lochia.

The correct answer focuses on administering prescribed medication to stabilize the overactive central nervous system seen during alcohol withdrawal. While the specific medications may vary, this intervention targets symptom control and reduces the risk of life-threatening complications such as seizures or delirium tremens. Assessing the last alcohol intake can guide understanding of the withdrawal timeline but does not directly address immediate symptoms or prevent worsening. Emotional reassurance is supportive but insufficient to manage physiological symptoms of withdrawal. Monitoring for hallucinations is a safety measure but does not actively mitigate withdrawal progression.

The correct answer reflects the American Academy of Pediatrics' (AAP) safe sleep guidelines, which emphasize placing infants on their backs for sleep on a firm mattress within a crib without loose bedding. This position significantly reduces the risk of SIDS. Allowing side-lying sleep increases instability, potentially leading to dangerous rollovers. Car seats are not safe sleeping environments because of the risk of positional asphyxia. Loose blankets in the crib can raise the risk of suffocation or overheating, which are factors associated with SIDS.

This statement is false. Hand-offs require the use of clear, standardized language to prevent miscommunication and enhance the accuracy of information exchange. Informal or non-standard language increases the risk of errors and confusion, which can compromise client safety. Clear and professional communication ensures that all care team members have a common understanding of client needs.

The correct answer is aligned with the best practice of using at least two identifiers to confirm client identity as mandated by safety guidelines. Asking the client to state their name and date of birth ensures active participation from the client. Matching these identifiers with the medical record reduces the chance of error. The incorrect answers fail to meet the criteria of using two reliable identifiers or are not aligned with safe practices. For example, room numbers are not unique identifiers and could lead to errors when clients are moved or rooms are misinterpreted.

Keeping the wound moist with a sterile saline dressing promotes an optimal healing environment. Moisture helps with epithelialization and new tissue growth while also reducing the risk of desiccation, which can delay healing. While applying hydrogen peroxide may seem appropriate to reduce infection risk, it can also harm healthy granulation tissue. Tape securing is necessary to keep the dressing in place but does not directly promote healing. Compression wraps, while useful in specific scenarios like venous insufficiencies, are inappropriate for a surgical wound with partial dehiscence.

The correct answer is to educate the client about the importance of lifestyle changes to manage modifiable risk factors like diet, exercise, and smoking cessation. A family history of heart disease increases the client’s risk, but managing modifiable factors can significantly mitigate this risk. Ordering a genetic test may not be the first step unless further clinical indicators suggest a specific need. Relying on routine labs alone may not fully capture the client’s individual risk, as lifestyle and family history are equally crucial. Focusing on general dietary guidelines lacks personalization necessary for effective education.

The introduction of solid foods typically begins around 6 months, and iron-fortified rice cereal mixed with breast milk or formula is a common starting option. This choice is recommended because it provides iron, an essential nutrient for infants at this stage, and is less likely to cause an allergic reaction compared to other foods. Offering pureed vegetables and fruits can be a good practice after initial solids like iron-fortified cereals, but it is not usually recommended as the very first food. Introducing whole milk before 12 months is discouraged because it lacks certain nutrients essential for infant growth and can tax immature kidneys. Providing water to a 6-month-old is unnecessary as long as they are consuming breast milk or formula, which adequately hydrates them.