NCLEX-PN Study Guide, Saunders/Silvestri 7th ed.

The nurse is planning to reinforce nutrition instructions to an African American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African American heritage?

Fried foods rationale: African American food preferences usually include chicken, pork, greens, rice, and fried foods.

The nurse is assisting with collecting data from an African American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of lowest priority during data collection?

Psychosocial rationale: the psychosocial data is the lowest priority during the initial admission data collection.

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is MOST IMPORTANT to provide to the client?

"You will need to talk to your primary health care provider before using an herbal substance" rationale: although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with a conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects, because the combination may lead to an excessive-reaction or unknown interaction effects.

Client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement?

"tell me what you know about complementary therapies" Rationale: assessing patient knowledge, as well as what therapies that they have in mind, will help to assess whether the therapies are compatible with their current course of treatment.

A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify (select all that apply):

1. many choose not to have health insurance 2. they believe health is a gift from God. 3. the authority of women is equal to that of men 4. they remain secluded and avoid helping others 5. they use both traditional and alternative health care, such as healers, herbs, and massage. 6. funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment. 1, 2, 5, 6

Which identifies accurate nursing documentation notations? (select all that apply)

1. the client slept through the night 2. abdominal wound dressing is dry and intact without drainage 3. the client seemed angry when awakened for vital sign measurement 4. the client appears to become anxious when it is time for respiratory treatments. 5. the client's left lower medial leg wound is 3cm in length without redness, drainage, or edema. 1, 2, 5

The nurse consults with a dietician regarding the dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan?

Rice rationale: Asian American food preferences usually include raw fish, rice, and soy sauce.

The nurse finds the client lying on the floor. The nurse calls the registered nurse who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurance. The nurse completes the incident report for which purpose?

A method of promoting quality care and risk management. rationale: proper documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result of the occurrence are internal to the institution or agency. Documentation on the incident report allows the nurse and administration to review the quality of care and determine potential risks present.

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications?

A ten-year-old female client with a urinary tract infection rationale: children should not be given herbal therapies, especially in the home and without professional supervision.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the clients signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Decline to sign the will. rationale: Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including the nurse in a facility which the client is receiving care.

A Hispanic American mother brings her child to the clinic for an examination. Which is MOST IMPORTANT when gathering data about the child?

Touching the child during the examination rationale: in Hispanic American culture, eye behavior is significant. It is believed that the "bad/evil eye" can be given to a child if a person looks at and admires the child without touching the child. Therefore, touching the child during the examination is very important.

An unconscious client, bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the BEST action?

Transport the client to the operating department immediately without obtaining informed consent. rationale: there are only two instances in which informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in the injury or death to the client. The second instance is when the client waives the right to give informed consent.

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which products with the primary health care provider?

Valerian rationale: valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous disorders such as anxiety and restlessness.

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal?

allowing the client to unwrap the utensils and prepare his own meal for eating. rationale: kosher meals arrive on paper plates and with plastic utensils sealed. It is most appropriate to allow the patient to unwrap their own utensils and arrange their dish.

The LPN enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider are notified of the incident. Which is the NEXT nursing action regarding the incident?

document a complete entry in the client's record concerning the incident. rationale: the incident report is confidential and privileged information, and it should not be copied, placed in the chart, or have any references made to it in the clients record. The incident report is not a substitute for a complete entry in the clients record concerning the incident.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

report to the pediatric unit and identify tasks that can be safely performed. rationale: floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally the nurse cannot refuse to float unless a union contract guarantees that the nurse can only work in a specified area or the nurse can prove a lack of knowledge for the performance of assigned tasks.