Nursing Leadership NCLEX Questions (41-45)

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41. When assessing the client with the vest restraint (security device) at the beginning of day shift, which observation by the charge nurse would indicate that the nurse who placed the vest restraint on the client failed to follow safety guidelines?

a) a hitch was used to secure the restraint
b) the call light was placed within reach of the client
c) the restraint was applied tightly across the client's chest
d) the client's record indicates that the restraint will be released every 2 hours

42. A male client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The nursing assistant assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the nursing assistant that:

a) enteric precautions should be instituted for the client
b) gloves and mask should be used when the in client's room
c) contact isolation should be initiated, because the diseases is highly contagious
d) standard precautions are sufficient, because the disease is transmitted sexually

43. A nursing assistant is caring for an older male client with cystits who has an indwelling urinary catheter. The registered nurse provides directions regarding urinary catheter care and ensures that the nursing assistant:

a) loops the tubing under the client's leg
b) places the tubing below the client's knee
c) uses soap and water to cleanse the perineal area
d) keeps the drainage bag above the level of the bladder

44. A nurse is planning care for a client with acute glomerulonephritis. The nurse instructs the nursing assistant to do which of the following in the care of the client?

a) ambulate the client frequently
b) monitor the temperature every 2 hours
c) encourage a diet that is high in protein
d) remove the water pitcher from the bedside

45. A nurse watches a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating doughnut next to the hemodialysis machine while talking with the client about the client's week. The first nurse should:

a) get a cup of coffee and join in on the conversation
b) determine whether or not the client would like a cup of coffee
c) admire the therapeutic relationship the second nurse has with the client
d) ask the second nurse to refrain from eating and drinking in the client area





Nursing Leadership NCLEX Questions:
Answers and Rationale

41) C

- A vest restraint should never be applied tightly because it could impair respirations. A hitch knot may be used on the client because it can easily be released in an emergency. The call light must always be within the client's reach in case the client needs assistance. The restraint needs to be released every 2 hours (or per agency policy) to provide movement.

42) D

- Chlamydia is a sexually transmitted disease. Caregivers cannot acquire the disease during administration of care, and standard precautions are the only measure that needs to be used.

43) C

- Proper care of an indwelling urinary catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement. The drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder, and, for the same reason, the drainage tubing is not placed or looped under the client's leg. The tubing must drain freely at all times.

44) D

- A client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction as well as monitoring weight and intake and output. The client may be placed on bed rest or at least encouraged to rest, because a direct correlation exists between proteinuria, hematuria, edema, and increased activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor the temperature as frequently as every 2 hours.

45) D

- A potential complication of hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), client families (at risk from contact with the client and with environmental surfaces), and staff (who may acquire the virus from contact with the client's blood). This risk is minimized by the use of standard precautions, appropriate handwashing and sterilization procedures, and the prohibition of eating, drinking, or other hand-to-mouth activity in the hemodialysis unit. The first nurse should ask the second nurse to stop eating and drinking in the client area.



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Nursing Leadership NCLEX Questions (1-5)


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Nursing Leadership NCLEX Questions (46-50)