🎯 High-Yield Points for This Topic
- Hand hygiene: most effective infection control measure; before and after every patient contact
- Fall prevention: highest risk = elderly + sedatives + recent surgery; use bed alarms, non-slip footwear
- Restraints: require provider order; assess every 2 hours; remove every 2 hours for range of motion
- Informed consent: client must be competent, voluntary, and have adequate information
- HIPAA: do not discuss client information in public areas; verify identity before disclosing
[Infographic: Fundamentals of Nursing NCLEX Questions Key Concepts — Clinical Manifestations, Nursing Interventions, Priority Actions]
Practice Questions
Question 1
A nurse is about to perform a urinary catheter insertion. Which action BEST prevents catheter-associated urinary tract infection (CAUTI)?
✓ Correct: Maintain strict aseptic technique throughout the insertion procedure
Strict aseptic technique during insertion is the most important CAUTI prevention measure. Once bacteria are introduced during insertion, a catheter infection almost inevitably follows. Changing catheters frequently actually increases CAUTI risk by repeated introductions. Clamping tubing promotes urine stasis (ideal bacterial growth). Routine irrigation is not standard practice and increases infection risk.
Strict aseptic technique during insertion is the most important CAUTI prevention measure. Once bacteria are introduced during insertion, a catheter infection almost inevitably follows. Changing catheters frequently actually increases CAUTI risk by repeated introductions. Clamping tubing promotes urine stasis (ideal bacterial growth). Routine irrigation is not standard practice and increases infection risk.
Question 2
A nurse finds a client on the floor next to the bed. After ensuring client safety, which action does the nurse take NEXT?
✓ Correct: Reassess the client for injury and obtain vital signs
After ensuring immediate safety (calling for help, not moving the client if injury suspected), the nurse's next priority is to thoroughly assess the client for injury — check vitals, level of consciousness, assess head, extremities, and spine. Notification and documentation follow the client assessment. Completing an incident report is done but not before the client is fully assessed and stable.
After ensuring immediate safety (calling for help, not moving the client if injury suspected), the nurse's next priority is to thoroughly assess the client for injury — check vitals, level of consciousness, assess head, extremities, and spine. Notification and documentation follow the client assessment. Completing an incident report is done but not before the client is fully assessed and stable.
Question 3
A client refuses a scheduled blood transfusion citing religious beliefs. Which action by the nurse is APPROPRIATE?
✓ Correct: Document the refusal, notify the provider, and respect the client's decision
A competent adult has the absolute legal and ethical right to refuse any treatment, including blood transfusions, even for religious reasons (e.g., Jehovah's Witnesses). The nurse must document the refusal, ensure the provider is notified, and ensure the client has given informed refusal (understands consequences). Overriding a competent client's refusal constitutes battery. Pressuring through family undermines autonomy.
A competent adult has the absolute legal and ethical right to refuse any treatment, including blood transfusions, even for religious reasons (e.g., Jehovah's Witnesses). The nurse must document the refusal, ensure the provider is notified, and ensure the client has given informed refusal (understands consequences). Overriding a competent client's refusal constitutes battery. Pressuring through family undermines autonomy.
Question 4
A nurse is preparing to apply a restraint to a confused elderly client who is pulling at their IV line. Which action is REQUIRED before applying restraints?
✓ Correct: Obtain a provider order for restraints
Restraints require a provider order before application in most jurisdictions. Restraints are a last resort after all other alternatives (moving the IV line, mittens, distraction, re-orienting, family presence) have been attempted. After application, the nurse must monitor the restrained client every 2 hours (assess circulation, skin integrity, range of motion) and document the ongoing need for restraints per facility policy.
Restraints require a provider order before application in most jurisdictions. Restraints are a last resort after all other alternatives (moving the IV line, mittens, distraction, re-orienting, family presence) have been attempted. After application, the nurse must monitor the restrained client every 2 hours (assess circulation, skin integrity, range of motion) and document the ongoing need for restraints per facility policy.
Question 5
A nurse is leaving a voicemail for a client to discuss their HIV diagnosis results. Which action is MOST appropriate?
✓ Correct: Request a return call without specifying the reason for calling
HIPAA (Health Insurance Portability and Accountability Act) requires protecting client privacy. Leaving diagnostic details on a voicemail risks disclosure to others who may access the phone. The correct action is to leave a message requesting a call back without identifying the reason, so the client can call in a private, secure setting. Never leave sensitive diagnoses on voicemail or with third parties.
HIPAA (Health Insurance Portability and Accountability Act) requires protecting client privacy. Leaving diagnostic details on a voicemail risks disclosure to others who may access the phone. The correct action is to leave a message requesting a call back without identifying the reason, so the client can call in a private, secure setting. Never leave sensitive diagnoses on voicemail or with third parties.
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[Clinical Concept Map: Fundamentals of Nursing NCLEX Questions — Pathophysiology, Assessment Findings, Nursing Actions]