NCLEX-PN Test #14 2 — Questions and Answers
Question 1: The PN is preparing to transfer a client from the bed to a wheelchair. The client weighs 200 lbs (91 kg) and has one-sided weakness. Which action ensures the safest transfer?
- Ask the client to push off the bed with the weak side
- Position the wheelchair on the client's stronger side and lock the wheels before transfer (Correct answer)
- Have the client stand quickly to minimize muscle strain
- Perform the transfer alone to maintain the client's independence
Correct answer: Position the wheelchair on the client's stronger side and lock the wheels before transfer
Positioning the wheelchair on the strong side allows the client to lead with the strong leg and pivot more safely. Locking wheels before transfer prevents the chair from sliding. For clients with one-sided weakness (hemiplegia), the strong side is used for stability. The gait belt provides additional safety for the nurse.
Question 2: A nurse receives a call from a person claiming to be the client's physician, requesting the client's HIV status over the phone. What is the correct response?
- Provide the information after verbally confirming the physician's name
- Provide the information only if the physician provides the client's full date of birth
- Inform the caller that HIV status is protected health information that requires identity verification per policy before disclosure (Correct answer)
- Release the information as physician requests take priority over privacy
Correct answer: Inform the caller that HIV status is protected health information that requires identity verification per policy before disclosure
HIV status is specially protected health information under both HIPAA and most state laws. Identity cannot be verified over the phone. The nurse must follow facility policy, which typically requires the provider to access information through authenticated EHR access. Verbal disclosure over phone to an unverified caller violates confidentiality.
Question 3: A nurse discovers a small fire in the client's room. Using the RACE protocol, what is the correct sequence?
- Rescue — Alarm — Contain — Extinguish (Correct answer)
- Alarm — Rescue — Contain — Extinguish
- Rescue — Contain — Alarm — Extinguish
- Extinguish — Rescue — Alarm — Contain
Correct answer: Rescue — Alarm — Contain — Extinguish
RACE fire response protocol: R — Rescue (remove persons in immediate danger), A — Alarm (activate fire alarm, call 911), C — Contain (close doors to limit spread), E — Extinguish (use fire extinguisher only if safe to do so). Client safety is the absolute priority before any other action.
Question 4: The nurse is reviewing a client's medication administration record and notes the client received the wrong dose of insulin 30 minutes ago. What is the priority action?
- Document the error in the chart and notify the supervisor at the next shift change
- Immediately assess the client, notify the provider, and complete an incident report (Correct answer)
- Ask a colleague to co-sign the error to validate the documentation
- Wait to see if the client develops symptoms before taking action
Correct answer: Immediately assess the client, notify the provider, and complete an incident report
After a medication error, priorities are: (1) assess the client for adverse effects (hypoglycemia from excess insulin), (2) notify the provider immediately for orders to monitor and treat, (3) complete an incident report per facility policy, and (4) document the client's condition and actions taken in the medical record. Patient safety first, then reporting.
Question 5: The PN is caring for a client with a latex allergy. Which item commonly found in the clinical environment may contain latex?
- Glass IV fluid bottles
- Vinyl exam gloves
- Tourniquets, some IV tubing, and stethoscope tubing (Correct answer)
- Stainless steel surgical instruments
Correct answer: Tourniquets, some IV tubing, and stethoscope tubing
Latex is found in many clinical items: rubber gloves, blood pressure cuffs, tourniquets, IV tubing injection ports, catheter balloons, stethoscope tubing, and tape backings. A latex-safe environment requires latex-free substitutes for all equipment. Cross-reactivity foods include bananas, avocados, kiwi, and chestnuts.
Question 6: A client is at high risk for falls. Which intervention is most evidence-based for preventing in-hospital falls?
- Apply side rails × 4 to prevent the client from getting out of bed
- Use a bed alarm, keep call light within reach, ensure non-skid footwear, and complete hourly rounding (Correct answer)
- Restrain the client with a vest restraint when unattended
- Administer a PRN sedative at bedtime to prevent nighttime wandering
Correct answer: Use a bed alarm, keep call light within reach, ensure non-skid footwear, and complete hourly rounding
Evidence-based fall prevention bundles include: bed and chair alarms, call light within reach, non-slip footwear, bed in lowest position, hourly rounding, toileting schedule, safe environment (clutter-free), and fall risk signage. Four-sided restraints and chemical restraints (sedatives) increase fall risk and are contraindicated as prevention strategies.
NCLEX-PN Test #14 2
The PN is preparing to transfer a client from the bed to a wheelchair.
The client weighs 200 lbs (91 kg) and has one-sided weakness.
Which action ensures the safest transfer?