PrepU NCLEX Unit1
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?
When communicating a change in a client's condition to his or her physician.
A nurse is caring for a client who also works in the hospital. The client has recently received a diagnosis of genital herpes and is being treated for a urinary tract infection (UTI). While on lunch break in the cafeteria, the nurse sees the client's coworkers, who voice concern over his condition. The nurse's best response would be:
"I'll be sure to tell him you're thinking of him."
A client with a history of alcohol abuse was admitted with bleeding esophageal varices. After several days of treatment, the client is ready for discharge. The nurse enters the client's room to review discharge instructions with the client when he tells the nurse that he wants help to quit drinking. How should the nurse respond?
"I'll notify your physician and call the social worker so she can discuss treatment options with you."
A nurse working in the emergency department receives an order from an orthopedic surgeon to obtain written consent from a client for the surgical repair of a fractured forearm. The surgeon has not seen the client but has reviewed the radiographs in the operating room between cases. Which of the following would be the most appropriate response by the nurse to the surgeon?
"It is your responsibility to obtain informed consent from the client."
A nurse working in a blood conservation program is being mentored by a supervising nurse. A client asks for information about iron supplements and epoetin alpa as alternatives to a blood transfusion. Which of the following responses by the nurse causes the supervising nurse to plan a review of professional and ethical standards?
"You should take the unit of blood. It will help you feel better."
A nurse is caring for a group of clients. After receiving shift report, the nurse should make rounds on the clients in which order? Place in order of the highest to lowest priority. All options must be used.
1- female client who is 34 years of age and just returning from the recovery room following an abdominal hysterectomy; IV running at 50 drops per minute with 100 mL remaining 2- client who is 79 years of age 2 days postsurgery for removal of cancer of the colon who has had a tracheotomy for 4 years 3- client who is 75 years of age with a fractured hip of 4 days who needs to be turned frequently 4- client who is 50 years of age and diagnosed with diabetes mellitus 3 days ago who is learning to administer insulin
Which registered nurse should be assigned to the client who had a chest tube inserted yesterday?
A registered nurse that use to work on the cardiovascular unit
When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort?
Acute pain
The following nursing diagnoses are formulated with a client: constipation, acute pain, and caregiver role strain. During the planning phase of the nursing process, the nurse will prioritize the diagnoses in what order?
Acute pain, constipation, caregiver role strain
A client with a history of hypertension and heart disease is being seen by the urologist because of erectile dysfunction. What would be the most likely cause of the client's erectile dysfunction?
All options are correct. (atherosclerosis, 0HTN meds, depression
A nurse is working within the managed care delivery model. Which of the following is true regarding managed care?
All systems reflect the values of efficiency and effectiveness.
A client exhibits hostility toward the persons from whom she wants love and approval. Which of the following states the client's condition?
Ambivalence
A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?
Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.
An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored?
Ask the client in a nonthreatening way if she wishes to have an epidural, and then speak with the physician.
A client is admitted to the mental health unit in the manic phase of bipolar disorder. The client refuses to take the prescribed medication. Which of the following would be the most appropriate action by the nurse?
Ask the client the reason for not taking the medication.
A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation?
Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members.
The nurse is caring for a client who cannot meet health needs independently. Which action made by the nurse depicts concern and attachment?
Asking the client, "How are you today? I am really worried about you."
A client in a long-term care facility refuses to take his oral medications. The nurse threatens that she will apply restraints and inject the medication if he doesn't take it orally. The nurse's statement constitutes which legal tort?
Assault
A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?
Charting by exception.
The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the most appropriate action by the nurse?
Consult with the prescriber regarding the need for an increased dose of the drug and not to reduce the frequency of administration.
A nurse faxes a client's medical record to the wrong physician's fax machine. Which of the following should be the immediate action by the nurse?
Contact the physician, ask that it be shredded, and complete an incident report.
The nurse has completed a head-to-toe assessment of a patient who was admitted for the treatment of heart failure (HF). Which of the following assessment findings should signal to the nurse a possible exacerbation of the patient's condition?
Crackles are audible on chest auscultation.
Which of the following terms refers to Leininger's description of the person's inability to recognize his or her own values, beliefs, and practices and those of others?
Cultural blindness
Which statement is a correct reason for nurses to become culturally sensitive and develop their cultural competency skills?
Cultural sensitivity and consideration of client diversity are necessary to provide ethical nursing care.
A client needs to be transferred to the oncology unit for further care. Which of the following information is necessary to include in the transfer report?
Current client assessment.
A nurse-manager notes that a staff nurse isn't working to full potential. Which strategy by the nurse-manager would best benefit the staff nurse?
Discussing the staff nurse's performance and ways it can be improved
A client has been admitted to the medical surgical unit following an emergency cholecystectomy. There is a Jackson Pratt drain with a portable suction unit attached. After 4 hours, the drainage unit is full. What should the nurse do?
Empty the drainage unit.
A health care agency is applying for accreditation, and the accrediting agency is conducting audits of randomly selected medical records. To support the agency's accreditation, these medical records should include:
Evidence that nursing interventions have been evaluated in terms of the client's response.
A clinic nurse is assigned to care for a suicidal client. During the preinteraction phase, what should the nurse's priority be?
Exploring the nurse's own feelings about suicide
At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress notes above and begins planning client care based on which nursing diagnosis?
Fear related to potential diagnosis of malignant melanoma.
What statement does the nurse determine is a medical diagnosis rather than a nursing diagnosis?
Fever of unknown origin
Which class of medication lyses and dissolves thrombi?
Fibrinolytic
A nurse-manager in a pediatric intensive care unit notices an increase in nosocomial infections. What should the nurse do next?
Gather data on possible reasons for this increase.
The National Center for Health Statistics uses data from healthcare agencies to issue quarterly and annual reports on performance related to goals for improving the health of the U.S. population. Which initiative is targeted with improving the health of all Americans?
Healthy People 2020
A client with severe combined immunodeficiency is to receive a hematopoietic stem cell transplant. Which of the following would the nurse expect to be started?
Immunosuppressive agents
A nurse discusses the HIV-positive status of a client with other colleagues. The client can sue the nurse for which of the following?
Invasion of privacy.
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes.
A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which of the following actions should the nurse take?
Note that the nurse caring for the client cannot be a witness.
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb all the way up to the hips. What should the nurse do next? Select all that apply.
Notify the health care provider (HCP) of the change. Place respiratory resuscitation equipment in the client's room. Check for advancing levels of paresthesia.
Which guidelines define and regulate what the nurse may and may not do as a professional?
Nurse practice act
A client is voiding small amounts of urine every 30 to 60 minutes. What should the nurse do first?
Palpate for a distended bladder.
A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent?
Protects the client's right to self-determination in health care decision making.
A hospital board of directors decides to close a pediatric burn treatment center (BTC) that annually admits 50 patients and to open a treatment center for terminally ill AIDS patients (with an expected annual admission of 200). This decision means that the nearest BTC for children is now 300 miles away. What example of ethical reasoning is this decision consistent with?
Utilitarianism
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?
Risk for injury related to neurologic deficit
A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?
Scrub role
In arteriosclerosis, commonly referred to as hardening of the arteries, the rigid arterial vessels fail to stretch. This has the potential for what?
Sending a reduced volume of oxygenated blood to the major organs of the body
A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, he has seen significant improvements in both his medical status and activities of daily living (ADLs). This morning, however, his nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which of the following practitioners should the nurse liaise with to obtain a swallowing assessment?
Speech therapist.
The nurse is caring for a patient who is to be discharged from the acute care facility to a rehabilitation unit after having a stroke. What type of prevention is this considered to be?
Tertiary
A registered nurse (RN) has been "care-paired" with a licensed practical nurse (LPN) during the evening shift. Whose care should the RN assign to the LPN?
The 2-year-old child who has started eating soft, solid foods following a tonsillectomy
A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first?
The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block
The nurse recognizes that the goals established for a client's discharge are more likely to be accomplished when:
The client assists in developing the goals.
A client has a nursing diagnosis of "Feeding self-care deficit related to right-sided weakness. Which of the following would be the most appropriate expected outcome for this client?
The client will demonstrate an ability to feed himself with a spoon at the morning meal.
The nurse caring for a 74-year-old man who has just returned to the surgical unit following surgery for a total knee replacement received report from the PACU. Part of the report had been passed on from the preoperative assessment, in which the patient stated that he has "gotten confused" in the past when he takes pain medications. The nurse should recognize which of the following principles of pain management among older adults?
The elderly may require lower doses of medication and are easily confused with new medications.
A graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first?
The newly admitted client with acute abdominal pain
Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients?
The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.
You are performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would you ask the client about the use of herbal supplements?
They prolong bleeding.
The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is:
To notify the surgeon
The nurse has received a change-of-shift report. The nurse should assess which client first?
a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08
The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which client care rooms is most appropriate for this client?
a darkened private room as close to the nurses' station as possible
A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client would be to:
assess for and maintain adequate nutrition and hydration.
The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion. The nurse manager of the operating room should:
change the assignment without comment.
A Jewish client requests an orthodox diet while hospitalized. The nurse should refer this request to the:
dietitian.
The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should:
explain how to overcome a freezing gait by telling the client to march in place.
A client is to be discharged from an alcohol rehabilitation program. What should the nurse emphasize in the discharge plan as a priority?
follow-up care
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for
recent foods ingested.
A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. His cholesterol profile is as follows: total cholesterol 265 mg/dl (6.845 mmol/L), low-density lipoprotein (LDL) 139 mg/dl (3.603 mmol/L), and high-density lipoprotein (HDL) 32 mg/dl (0.829 mmol/L). The client asks the nurse how to lower his cholesterol. The nurse should tell the client that:
she'll ask the dietitian to talk with him about modifying his diet.
Which finding is an expected outcome for an elderly client following treatment for bacterial pneumonia?
the ability to perform activities of daily living without dyspnea
A client who has a lengthy history of progressive hearing loss is very forthright about the condition, and the nurse wants to develop a communication strategy for this client's hospital stay. Which communication strategy has proven to be the most effective?
the one the client will use
An elderly client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that:
the rings will be placed in an envelope, the client will sign the envelope, and the envelope will be placed in a safe.
