NUR 2050 Skills (NCLEX Questions)

A nurse is preparing to perform a general survey of a client who was admitted to the hospital a few hours ago. Which components of the general survey may be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assessing the skin surfaces 2. Observing the client's 3. Measuring the client's height and weight 4. Assessing the client's general appearance 5. Monitoring oral intake and urinary output

-Measuring the client's height and weight -Monitoring oral intake and urinary output

A client diagnosed with terminal cancer says to the nurse, "I'm going to die and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? a. Have you shared your feelings with your family? b. I think we should talk about your anger with your family c. You're feeling angry that your family continues to for hope for you to be cured? d. You are probably very depressed, which is understandable with such a diagnosis

C.

A client's abdominal incision eviscerates. The nurse should: A. Take the client's vital signs and call the physician. B. Lower the client's head and elevate the feet. C. Cover the incision with a dressing moistened with sterile normal saline solution. D. Start an emergency infusion of I.V. Fluids.

C.

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant? a. Assisting the patient to sit up on the side of the bed b. Instructing the patient to cough effectively c. Teaching the patient to use incentive spirometry d. Auscultation of breath sounds every 4 hours

Assisting the patient to sit up on the side of the bed

The nurse finds the client who has an ileostomy crying. The client explains to the nurse, "I'm upset because I know I won't be able to have children now that I have an ileostomy." Which response by the nurse is best? a. Many women with ileostomies decide to adopt. Perhaps you could consider that. b. Having an ileostomy doesn't necessarily mean that you can't bear children. Let's talk about your concerns. c. I can understand your reasons for being upset. Having children must be important to you. d. I'm sure you will adjust to this situation with time. Try not to be too upset.

B

The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate- controlled diet has been prescribed but the client has been complaining of nausea and is not eating. On entering the client's room, the nurse finds the client to be confused and diaphoretic. Which action is most appropriate at this time? A. Call a code to obtain needed assistance immediately. B. Obtain a capillary blood glucose level and perform a focused assessment. C. Ask the unlicensed assistive personnel (UAP) to stay with the client while obtaining 15 to 30 g of a carbohydrate snack for the client to eat. D. Stay with the client and ask the UAP to call the health care provider (HCP) for a prescription for intravenous 50% dextrose.

B

A client admitted with pneumonia and dementia has attempted several times to pull out the IV and foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate? a. Perform circulation checks to bilateral upper extremities each shift b. Attach the ties of the restraints to the bed frame c. Reevaluate the need for restraints and document weekly d. Ensure the restraint prescription has been signed by the health care provider within 72 hours

B.

A client placed in isolation for Tuberculosis asks the nurse why staff and visitors must wear masks when in the patient's room. What response by the nurse indicates understanding of TB isolation? a. Masks are part of the isolation uniform that everyone must wear b. The mask protects staff and visitors from contracting the disease and passing it to others c. The mask protects you from the germs staff and visitors carry in the room d. Why are staff and visitors wearing masks in your room? They don't need to

B.

A client is newly admitted with a diagnosis of left-sided heart failure. On assessment of the client, which findings should a nurse expect? A. Chest tightness and ascites B. Dyspnea on exertion and ascites C. Dyspnea on exertion and crackles D. Neck vein distention and crackles

C

A client with a neurological impairment experiences new onset urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this condition? A. Using adult diapers B. Inserting a Foley catheter C. Establishing a toileting schedule D. Padding the bed with an absorbent cotton pad

C

A client, with the diagnosis of congestive heart failure (CHF), contacts a clinic nurse and states, "I don't know why my ankles are so fat." What is the most appropriate initial response by the clinic nurse? A. "Tell me about your activity level." B. "What have you eaten in the last 24 hours?" C. "Have you weighed yourself today?" D. "How different are they from yesterday?"

C

A client scheduled to take a subcutaneous anticoagulant at home says to the nurse, "I'm not sure I will be able to take this medication at home." Which statement by the nurse is MOST appropriate? a. Maybe your spouse can give you your shots b. You'll be fine once you get used to giving your own shots c. What are your concerns about taking this medication at home? Don't worry. Your healthcare provider knows what's best for you

C.

The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question? a. Have the client talk with a member of the clergy about these concerns b. Tell the client to worry about those concerns after surgery c. Arrange for a person with an ostomy to visit the client perioperatively d. Notify the surgeon of the client's question

C.

After change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

D

Prior to being transported to the surgery suite, the nurse asks the client whether the client has any allergies. The client responds, "Does anyone communicate with anyone? I've been asked that question over and over!". What is the nurse's best response? a. I'm sorry! I just have to ask that question for the record b. It's an important question, and we just have to check. c. You will hear it again and again as you go through surgery. d. This question is asked for verification and safety with each new phase of treatment.

D

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A. A client scheduled for a chest x-ray B. A client requiring daily dressing changes C. A postoperative client preparing for discharge D. A client receiving nasal oxygen who had difficulty breathing during the previous shift

D

Which nursing diagnosis is the highest priority for the client experiencing heart failure? A. Excess fluid volume B. Disturbed sleep pattern C. Activity intolerance D. Impaired gas exchange

D

A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? a. You have everything to live for b. Why do you see yourself as a failure c. Feeling like this is all part of being depressed d. You've been feeling like a failure for a while

D.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? a. Patient complaining of muscle aches, a headache, and malaise b. Patient who twisted her ankle when she fell while roller-blading c. Patient with a minor laceration on the index finger sustained while cutting an eggplant d. Patient with chest pain who states that he just ate pizza that was made with a very spicy sauce

D.

The nurse is assigned to care for a patient with pneumonia. Which task can be delegated to the unlicensed assistive personnel by the RN? a. Teaching a patient how to use the inhaler b. Listening to the patient's lungs c. Checking the results of the patient's blood work d. Counting the patient's respiratory rate

D.