NCLEX-RN Practice Questions

Shortening of the affected leg with internal or external rotation are classic signs of hip prosthesis dislocation, which is a medical emergency. This finding requires immediate notification of the surgeon and intervention to prevent neurovascular damage. Moderate pain, expected drainage, and the presence of an abduction pillow are normal findings.

The principle of least restrictive intervention requires the nurse to first assess for and address any underlying physiological or psychological causes of agitation before resorting to restraints. In a client with dementia, agitation can be a sign of pain, hypoxia, infection, constipation, or other discomforts they cannot verbalize. A physician's order is required for restraints, but only after less restrictive measures have failed. Applying restraints without a thorough assessment is inappropriate.

This statement indicates a need for further education. Children with cystic fibrosis have difficulty absorbing fats due to pancreatic insufficiency and require a high-fat, high-calorie, high-protein diet to meet their nutritional needs. They also lose excess salt in their sweat and often require salt supplementation, not restriction. The other statements reflect correct understanding of CF management.

The client is exhibiting signs of a febrile non-hemolytic transfusion reaction. The absolute first priority is to stop the transfusion to prevent further administration of the causative agent. Next, maintain IV access with normal saline using new tubing to avoid infusing more blood from the old tubing. Then, notify the provider of the reaction. Finally, continue to monitor the client by rechecking vital signs. This sequence ensures immediate safety and appropriate escalation of care.

Bacterial meningitis is highly contagious and spread by droplets. The first priority upon suspicion of the diagnosis is to implement droplet precautions to prevent transmission to healthcare workers and other patients. This action must be taken even before other necessary interventions like starting antibiotics or performing diagnostic tests.

For an acute DVT, the goals are to reduce inflammation, prevent embolization, and promote comfort. Applying warm, moist compresses can help reduce discomfort and inflammation. Massaging the leg is contraindicated as it can dislodge the clot. Strict bed rest is no longer universally recommended, and ambulation is often encouraged once anticoagulation is therapeutic. Cold compresses would cause vasoconstriction, which is not desired.

While all points are important, evidence shows that the most significant factor in reducing CAUTI rates is minimizing the duration of catheterization. The risk of infection increases for every day the catheter remains in place. Implementing a nurse-driven protocol that empowers nurses to assess for continued need daily (F) and remove catheters promptly when no longer indicated (H) is the most effective and critical intervention to reduce overall infection rates. Sterile insertion and daily care are crucial but do not address the primary risk factor: duration.

The most appropriate initial response is to use therapeutic communication, acknowledging the parent's perspective while providing essential health information. This approach respects the parent's beliefs, builds trust, and opens a dialogue about the importance of a definitive medical diagnosis to guide any treatment, whether conventional or complementary. Insisting on a referral or documenting refusal without education is non-therapeutic. Directly stating that chiropractic care is ineffective can alienate the parent and shut down communication.

Given the client's suicidal ideation and escalating withdrawal (refusing food/fluids), safety is the absolute priority. One-to-one observation is necessary to prevent self-harm.

The refusal of food and fluids poses a physiological risk (dehydration, electrolyte imbalance) that must be addressed urgently. This is a critical physiological need secondary only to immediate safety from self-harm.

This statement indicates correct understanding of the protocol for taking nitroglycerin for chest pain. The client should take one tablet, wait five minutes, and if pain persists, call 911 immediately. They may take up to two more doses five minutes apart while waiting for emergency services. Keeping the medication in sunlight degrades it. Driving to the hospital is unsafe. Waiting for a third tablet before calling 911 delays critical emergency response.