Leadership NCLEX Questions (56-60)

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56. A nurse receives a telephone calls from emergency department and is told that a client in leg traction will be admitted to the nursing unit. The nurse prepares for the arrival of the client and asks the nursing assistant to obtain which item that will be essential for helping the client move in bed while in leg traction?

a) a foot board
b) extra pillows
c) a bed trapeze
d) an electric bed

57. A registered nurse is observing a nursing student auscultate the breath sounds of a client. The registered nurse intervenes if the nursing student performs which incorrect action?

a) use the bell of the stethoscope
b) asks the client to sit straight up
c) places the stethoscope directly on the client's skin
d) has the client breathe slowly and deeply through the mouth

58. A nurse has oriented a new employee to basic procedures for continuous electrocardiogram (ECG) monitoring. The nurse would intervene of the new employee did which of the following while initiating cardiac monitoring on a client?

a)  clipped small areas of hair under the area planned for electrode placement
b) stated the need to change the electrodes and inspect the skin every 24 hours
c) stated the need to use hypoallergenic electrodes for clients who are sensitive
d) cleansed the skin with Betadine (povidone-iodine) before applying the electrodes

59. A client has an order for seizure precautions, and a nursing student develops a plan of care for the client. The registered nurse reviews the plan of care with the student and will instruct the student to remove which of hte following interventions?

a)  keep all the lights on in the room at night
b) assist the client to ambulate in the hallway
c) monitor the client closely while the client is showering
d) push the lock-out button on the electric bed to keep the bed in the lowest position

60. A client with active tuberculosis (TB) is to be admitted to a medical-surgical unit. When planning a bed assignment, the nurse:

 a) plans to transfer the client to the intensive care unit
b) places the client in a private, well-ventilated room
c) assigns the client to a double room because intravenous antibiotics will be administered
d) assigns the client to a double room and places a "strict handwashing" sign outside the door

Leadership NCLEX Questions
Answers and Rationale

56) C
- A trapeze is essential to allow the client to lift straight up while being moved so that the amount of pull exerted on the limb in traction is not altered. A foot board and extra pillows do not facilitate moving. Either an electric bed or a manual bed can be used for traction, but this does not specifically assist the client with moving in bed.

57) A
- The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the stethoscope, which is warmed before use, is placed directly on the client's skin, not over a gown or clothing.

58) D
- The skin is cleansed with soap and water (not Betadine), denatured with alcohol, and allowed to air-dry before electrodes are applied. The other three options are correct.

59) A
- A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a nightlight for safety. The client should be accompanied during activities such as bathing and walking, so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in low position for safety.

60) B
- According to category-specific (respiratory) isolation precautions, a client with TB requires a private room. The room needs to be well-ventilated and should have at least six exchanges of fresh air per hour and should be ventilated to the outside if possible. Therefore, option 2 is the only correct option.

After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Leadership NCLEX Questions (1-5)

Or proceed to the next set of questions:

Leadership NCLEX Questions (61-65)