Review Questions for the NCLEX Examination

A local disaster results in multiple injuries that will require hospitalization. The nurse manager at the only acute care facility in the community will need to clear beds for the new admissions. Which clients will the nurse manager decide to discharge? (Select all that apply.) 1. A client who delivered her third child vaginally 18 hours prior. 2. A middle-aged client who had a hip replacement 24 hours prior. 3. An adult client diagnosed with pneumonia receiving IV antibiotics. 4. An older client diagnosed with a stroke due to a brain bleed. 5. A school-age client who was just admitted due to an asthma attack.

1,2 CORRECT - A client who delivered her third child vaginally 18 hours before can be discharged. Teaching will be provided to make sure the client is aware of the signs of complications and when to contact the health care provider. CORRECT - A middle-age client who is 24 hours postoperative for hip replacement can be discharged from acute care. Further assessment is needed to determine if the client will be discharged home or to a rehabilitation facility. An adult client diagnosed with pneumonia who is receiving IV antibiotics cannot be discharged at the current level of care and treatment. The client would be a candidate if oral medication can be substituted for the IV drugs. However, there is not enough information to make this determination. An older adult client diagnosed with a stroke due to a brain bleed cannot be discharged due to possible instability and/or complications. The manifestations of stroke from a brain bleed will continue to develop until the brain bleed is stabilized. There is no information to support stabilization. A school-age client just admitted because of an asthma attack cannot be discharged because of a need for beds. Hospitalization of this client is indicative of instability and/or the possibility of complications.

The nurse manager in a pediatric clinic presents an in-service program to staff members about parental consent requirements. After the program, which clients will the nurse expect staff to recognize as needing parental consent? (Select all that apply.) 1. A minor in college who requires emergency surgery. 2. A minor who is married and the parent of a toddler child. 3. Minors who are determined to be emancipated by a court. 4. A school-age client who lives with a grandparent and requires an MRI. 5. An adolescent who seeks screening for a sexually transmitted infection.

1,4 CORRECT - A minor who is in college and requires emergency surgery will need parental consent. An exception would be if the minor were emancipated, which is not indicated. A minor who is married and is a parent of a toddler child is considered emancipated. This client would not need parental consent for medical treatment. Minors who are emancipated by the court do not need parental consent for medical care. CORRECT - A school-age client who is currently living with a grandparent will still require parental consent for medical treatment. An exception is if the grandparent has full custody of the client, which is not indicated. An adolescent client who is seeking screening for a sexually transmitted infection (STI) does not need parental consent. This is an exception to allow minors to seek medical treatment in a confidential manner. Without such an exception, the opportunity for assistance may be lost.

It is important to assess a patient's actual cultural beliefs because: 1. A patient may not adhere to the usual health beliefs. 2. Cultural beliefs play a major role in how the patient perceives herself. 3. The family's beliefs are inherent in the patient. 4. Cultural diversity is present in all parts of the United States.

1. A patient may not adhere to the usual health beliefs.

Attributes of critical thinkers include: (Select all that apply.) 1. Admitting what you don't know. 2. Consulting with primary care providers. 3. Anticipating problems. 4. Reflecting on experience. 5. Accepting others' decisions. 6. Being confident about your decisions. 7. Recognizing inconsistencies in gathered data.

1. Admitting what you don't know. 3. Anticipating problems. 4. Reflecting on experience. 6. Being confident about your decisions. 7. Recognizing inconsistencies in gathered data. Rationale: All correct choices involve the elements of critical thinking described in this chapter; the two incorrect choices require no critical thinking skills, because they are akin to "following orders."

The LPN/LVN reinforces teaching for a client that requires an increased magnesium intake. What food should the LPN/LVN recommend? 1. Apples and pears 2. Beef and corn 3. Chicken and fish 4. Squash and green beans

1. Apples and pears. CORRECT - Magnesium is high in fruit, green vegetables, fish, and whole grains. Some magnesium but not the best source. Not high in chicken but is in fish. Not high in squash but is in green beans.

The LPN/LVN reinforces dietary to an adolescent who is a lactovegetarian. What food combinations BEST make a complete protein? 1. Beans and rice 2. Cereal with milk 3. Lettuce and tomato salad. 4. Macaroni and cheese

1. Beans and rice CORRECT - Incomplete proteins in foods from plants must be mixed together to make a complete protein; beans and rice are incomplete proteins that when mixed, create a complete protein; lactovegetarian diet includes fruits, vegetables, nuts,seeds, beans, milk, cheese, yogurt, milk products and does not include animal protein products (meats), fortified foods. Cereal is an incomplete protein made from grains; milk is from an animal source and is therefore a complete protein. Lettuce and tomato are plant sources of incomplete proteins but together do not make a complete protein. Macaroni is a grain product and therefore an imcomplete protein; cheese is a complete protein.

A client is discharged home following treatment in an acute care facility for emboli in the lower extremities. The client is directed about how to take a prescribed anticoagulant. Which home management instructions does the nurse include for this client? (Select all that apply.) 1. Refrain from contact sports 2. Do not sit with crossed legs. 3. Use a soft bristle toothbrush. 4. Avoid tight or restrictive clothing on legs. 5. Avoid contact with pets that bit or scratch. 6. Report swelling or pain in lower extremities.

1. CORRECT - A client on anticoagulant therapy should refrain from contact sports, or any activity that can cause bumps and/or bruising. 2. CORRECT - A client with a history of emboli in the lower extremities should avoid sitting with crossed legs. This position hinders circulation, causes swelling, and can contribute to clot formation, even when on anticoagulant therapy. 3. CORRECT - A client on anticoagulant therapy needs to use a soft bristle toothbrush to prevent bleeding gums. 4. CORRECT - A client with a history of emboli in the lower extremities should avoid tight or restrictive clothing on the legs. Prevention of emboli due to hindered circulation, even while on anticoagulant therapy, is important. 5. CORRECT - A client on anticoagulant therapy needs to avoid any situation that creates a danger for the skin being broken. Pets that bite or scratch should be avoided to prevent bleeding. 6. CORRECT - A client with a history of emboli in the lower extremities needs to be aware that swelling or pain can be indicative of new clot formation. The client needs to be aware even while on anticoagulant therapy.

The LPN/LVN cares for an adolescent diagnosed with anorexia nervosa. The LPN/LVN determines the client understands the dietary education about a high protein, high kilocalorie diet when the client chooses which diet? 1. Cheeseburger with lettuce and tomato, French fries, watermelon slice, and cola. 2. Fruit salad, lime sherbet, carrot and celery sticks, skim milk 3. Rice, green beans, carrots, kale, squash, and water. 4. Vegetable soup, tossed salad, crackers, iced tea

1. Cheeseburger with lettuce and tomato, French fries, watermelon slice, and cola. CORRECT - Cheeseburger is high in protein and calories; other items also high in calories. Milk has some protein but no other food item does; calories are limited in all food items. Limited calories and no protein in food items. Limited calories and no protein in food items.

Which principle is most important when setting priorities for patient care? 1. Classifying nursing diagnosis and interventions as high, medium, and low. 2. Reevaluate and assess your priorities every 45 minutes. 3. Respond to the loudest, most difficult patient first so the others can rest. 4. Keep patients with visiting family well informed, but delay treatments.

1. Classifying nursing diagnosis and interventions as high, medium, and low. Rationale: Ranking allows for evaluation of what is potentially life-threatening and what is less harmful. Thinking through all possible options and outcomes allows for the best prioritization.

Which action(s) violate the HIPAA? (Select all that apply.) 1. Discussing the comatose patient's condition with his father-in-law. 2. Discussing the outcome of a patient's test with another nurse from the unit while in a crowded elevator. 3. Relaying information about the patient's concerns to the nurse who will care for him on the next shift. 4. Relaying a complaint about the quality of nursing care by the patient's wife to the charge nurse. 5. Updating your social media site about a difficult clinical day, including the hospital and patient's diagnosis, but NOT the patient's name.

1. Discussing the comatose patient's condition with his father-in-law. 2. Discussing the outcome of a patient's test with another nurse from the unit while in a crowded elevator.. 5. Updating your social media site about a difficult clinical day, including the hospital and patient's diagnosis, but NOT the patient's name. Rationale: Patient medical information is private, and all of these examples would constitute an invasion of the patient's prvacy about medical information, be against the HIPAA privacy rule, and be unethical according to nursing standards.

In setting up her nurses' training, Florence Nightingale carried out her belief that: (Select all that apply.) 1. Fresh, clean air is beneficial to the sick. 2. Sick people need adequate nutrition. 3. Nursing should be taught by nurses. 4. Proper nutrition is essential to recovery from illness. 5. Any woman could be trained to be a nurse.

1. Fresh, clean air is beneficial to the sick. 2. Sick people need adequate nutrition. 3. Nursing should be taught by nurses. 4. Proper nutrition is essential to recovery from illness.

A difference in the assessment of the patient entering a long-term care facility versus that of a hospital patient is that the long-term care resident is assessed for: 1. Functional abilities 2. Psychosocial concerns 3. Emotional concerns 4. Skin problems

1. Functional abilities Rationale: Functional abilities are assessed to determine how much assistance with activities of daily living the resident will need while in the facility.

Which is the best description of homeostasis? 1. It is the tendency of the body to adjust constantly to changing conditions. 2. It occurs when the equilibrium of the body is disturbed. 3. It is the biologic reaction that takes place in response to a stressor. 4. It is a static condition of the body during health.

1. It is the tendency of the body to adjust constantly to changing conditions.

Evidence-based nursing is based on: (Select all that apply.) 1. Professional nursing expertise. 2. Evidence from research that guides decision making. 3. Patient values and preferences. 4. Critical thinking, experience, and collaboration. 5. Nursing values and preference.

1. Professional nursing expertise. 2. Evidence from research that guides decision making. 3. Patient values and preferences.

Inherent in any definition or philosophy of nursing care are several core concepts. The core concepts include: (Select all that apply.) 1. Promoting wellness. 2. Restoring health. 3. Facilitating coping. 4. Sacrificing self for others. 5. Preventing illness.

1. Promoting wellness. 2. Restoring health. 3. Facilitating coping. 5. Preventing illness.

You assist a patient with her bath, change her dressing, rub her back, give her medication, review her dietary needs, and assist with physical therapy exercises. Which are examples of interdependent nursing actions? (Select all that apply.) 1. Reinforcing dietary education 2. Changing her dressing. 3. Assisting with her exercises 4. Giving her a back rub 5. Giving a bath 6. Administering medication

1. Reinforcing dietary education 3. Assisting with her exercises Rationale: (1) Diet is prescribed by the primary care provider and the dietary patient education is done by the dietitian. The nurse reinforcing that patient education is an interdependent action. (2) Exercises are prescribed by the primary care provider and taught by the physical therapist. The nurse assisting the patient to do the exercises is an interdependent action. Dressing changes and medication administration are dependent actions; backrub and bath are considered independent nursing actions.

An example of a dependent nursing action would be: 1. Starting the continuous passive motion (CPM) machine. 2. Providing a back massage. 3. Encouraging the consumption of more fluid. 4. Changing the patient's linens after an episode of incontinence.

1. Starting the continuous passive motion (CPM) machine. Rationale: The use of a CPM machine always requires an order, and starting the machine is a dependent action; a back massage, encouraging fluids, and changing linens when soiled do not require an order.

Priorities of caregiving change constantly because: (Select all that apply.) 1. The nurse's workload may change as patients are admitted. 2. Primary care providers' orders may change throughout the shift. 3. A patient's condition may deteriorate. 4. Tests or therapies involve scheduled time off the unit. 5. Many visitors are in the room to assist the patient.

1. The nurse's workload may change as patients are admitted. 2. Primary care providers' orders may change throughout the shift. 3. A patient's condition may deteriorate. 4. Tests or therapies involve scheduled time off the unit.

How do concept maps assist critical thinking? (Select all that apply.) 1. They help point out relationships among the data. 2. They link interventions, health problems, and nursing diagnoses. 3. They provide a timeline pattern to improve planning. 4. They help students synthesize pertinent data. 5. They identify care coordination roles using color codes.

1. They help point out relationships among the data. 2. They link interventions, health problems, and nursing diagnoses. 4. They help students synthesize pertinent data. Rationale: Concept maps can help you see relationships within a concept or relationships between interventions, health problems, and nursing diagnoses can be linked and pertinent assessment data is better synthesized. Concept mapping is not typically associated with timelines or color coding.

The nurse administrator for an acute care facility is aware the facility is located in a community with a high population of lesbian, gay, bisexual, and transgender (LGBT) clients. Which change within the facility does the nurse sponsor to meet the medical needs of LGBT clients? 1. Recruit LGBT nurses to provide care for LGBT clients. 2. Create an environment that welcomes and includes LGBT clients. 3. Educate staff members about the unique medical beliefs of LGBT clients. 4. Hold an open house at the facility and invite members of the LGBT community.

2 Specifically recruiting LGBT nurses to care for LGBT clients is discriminatory. All nurses should be encouraged to respect the cultural differences of all clients, regardless of race, religion, or sexual orientation. CORRECT - The facility should take steps to provide a welcoming environment for LGBT clients. Some actions would include posting non-discriminatory policy in obvious locations, providing unisex or one stall bathroom facilities, and including LGBT language on forms, such as "partner" or "partnered" as a choice for relationship status. The facility staff should receive education about cultural sensitivity. LGBT clients have the same medical beliefs as other clients. There are not unique medical beliefs in this population. However, it is important to remember that medical beliefs can be unique to individuals for reasons other than sexual orientation. Holding an open house for members of the LGBT community is insensitive and disrespectful. No group of persons should be focused on because of cultural differences.

Your patient has experienced severe complications during surgery and remains on life support. Decisions about care can be more easily made if the patient has which documents in place? 1. A power of attorney over financial affairs. 2. An advance directive. 3. A will. 4. No special documentation is needed.

2. An advance directive. Rationale: An advance directive would provide direction for making decisions in the event a patient's condition is such that he cannot make the decision himself.

The patient's temperature is 100.4°F (38°C). The skin on her forehead is warm and dry. She has been incontinent, and her bed is wet. She complains of being very tired. Which nursing intervention would be the highest priority? 1. Allow patient to rest. 2. Change the bed linens and gown. 3. Medicate for headache pain. 4. Apply lotion to the skin.

2. Change the bed linens and gown.

The American Red Cross was founded by ________________________, as an outgrowth of service during the _______________________ War. 1. Dorothea Dix, First World 2. Clara Barton, Civil 3. Lillian Wald, Second World 4. Florence Nightingale, Crimean

2. Clara Barton, Civil

When setting priorities of patient needs according to Maslow's hierarchy, you should: (Select all that apply.) 1. Only consider physiologic needs. 2. Consider airway status first. 3. Consider safety a high priority. 4. Place self-esteem needs before security needs. 5. Place activity needs before belonging needs. 6. Consider elimination needs before rest and comfort needs.

2. Consider airway status first. 3. Consider safety a high priority. 5. Place activity needs before belonging needs. 6. Consider elimination needs before rest and comfort needs.

A postoperative patient is having incisional pain. As part of the nurse's assessment, the nurse notes that the patient is grimacing when he or she changes position. The patient's grimace can be useful in the assessment and can be described in what manner? 1. Nursing diagnosis 2. Cue 3. Diagnosis 4. Inference

2. Cue Rationale: A cue is a piece of data that influences clinical decisions. In this example, the grimacing of a postoperative patient "cues" the nurse that the patient may be experiencing discomfort.

The LPN/LVN reinforces dietary education about food sources high in calcium to a client diagnosed with chronic kidney disease. The client exhibits signs and symptoms of hypocalcemia. What foods should the LPN/LVN include? 1. Eggs 2. Green leafy vegetables 3. Milk 4. Nuts

2. Green leafy vegetables. Also high in phosphorus; chronic kidney disease causes a rise in phosphorus while decreasing calcium; many foods that are high in calcium are also high in phosphorus. CORRECT - One of the few foods high in calcium and not phosphorus. High in phosphorus and calcium. High in phosphorous and not in calcium.

Which is the etiologic factor in the nursing diagnosis decreased mobility r/t left-sided muscular weakness, as evidenced by the inability to use the left arm for ADLs? 1. Decreased mobility 2. Left-sided muscular weakness 3. As evidenced by 4. Inability to use the left arm

2. Left-sided muscular weakness Rationale: Left-sided weakness is the etiology for the nursing diagnosis of decreased mobility.

Critical thinking will help you in the clinical setting to: 1. Delegate work more efficiently 2. Make good decisions most of the time. 3. Identify the best nursing diagnoses. 4. Write care plans more effectively.

2. Make good decisions most of the time. Rationale: Critical thinking skills will help you make sound clinical decisions much of the time; this is the most comprehensive answer choice. Delegation may require critical thinking skills; however, not every state allows LPNs/LVNs to delegate. Identifying nursing diagnoses and developing care plans is the responsibility of the RN.

The role of the LPN/LVN in the patient admission procedure differs from that of the RN and might include: (Select all that apply.) 1. Writes nursing diagnoses for the patient's care plan. 2. Obtains an ordered urine specimen. 3. Takes the patient's history. 4. Assists with physical data collection. 5. Orients the patient to the unit.

2. Obtains an ordered urine specimen. 3. Takes the patient's history. 4. Assists with physical data collection. 5. Orients the patient to the unit.

Which is a correctly stated expected outcome? 1. Sit in the chair three times a week. 2. Patient will walk to the end of the hall this week. 3. Use the incentive spirometer every 2 hours for 3 days. 4. Patient will respond to pain medication.

2. Patient will walk to the end of the hall this week. Rationale: Patient will walk to the end of the hall this week is the correctly written expected outcome because it contains a subject, an action, and a time frame for the action to be accomplished.

An advantage to the patient of a managed health care system is: 1. Always receiving care from the same provider. 2. Paying lower health insurance costs and smaller copayments. 3. The ease of quickly seeing a specialist. 4. Being able to walk into the clinic without an appointment.

2. Paying lower health insurance costs and smaller copayments.

The nurse is planning illness prevention activities for her patients. The best activity to choose would be: (Select all that apply.) 1. Applying a dressing to a wound. 2. Performing vision screenings. 3. Referring a patient to a care provider. 4. Promoting prenatal care. 5. Performing nutritional education.

2. Performing vision screenings. 4. Promoting prenatal care. 5. Performing nutritional education.

A patient confides that her broken arm is the result of her husband's abuse of her. In this instance, the nurse is required to: 1. Get a second nurse to witness her statement. 2. Report the abuse to the authorities. 3. Assure the patient that the information will be kept private. 4. Confirm the abuse with another family member and then notify the charge nurse.

2. Report the abuse to the authorities. Rationale: Nurses have a duty to report any suspected abuse and cannot keep the information "private."

Your patient asks you, "What do you think of my physician?" You mention that the physician does not seem to care about her patients or how well their symptoms are managed. As a result, the patient switches to another physician. The physician may have grounds to sue you for: 1. Malpractice. 2. Slander. 3. Libel. 4. Invasion of privacy.

2. Slander

The patient's temperature is 100.4°F (38°C). The skin on her forehead is warm and dry. She has been incontinent, and her bed is wet. She complains of being very tired. Which data are subjective? (Select all that apply.) 1. Temperature is 100.4°F (38°C). 2. States, "I'm very uncomfortable." 3. Bed is wet. 4. Complains of being very tired. 5. States, "I have a headache."

2. States, "I'm very uncomfortable." 4. Complains of being very tired. 5. States, "I have a headache."

Before carrying out a dependent nursing action, the nurse: (Select all that apply.) 1. Makes certain the family is in agreement with the order. 2. Verifies that the primary care provider's order is in the medical record. 3. Considers whether there is any contraindication for the action. 4. Reviews agency policies and procedures manual as needed. 5. Gathers all equipment and supplies needed for the action.

2. Verifies that the primary care provider's order is in the medical record. 3. Considers whether there is any contraindication for the action. 4. Reviews agency policies and procedures manual as needed. 5. Gathers all equipment and supplies needed for the action.

The nurse assigned to four clients receives the shift report and assumes care. Which nursing action reflects the nurse's ability to manage the assigned client care workload effectively? 1. Assign routine are to a nursing assistive personnel (NAP) and LPN/LVN. 2. Ask the charge nurse to assign additional personnel to provide client care. 3. Identify the status of each client and plan care based on needs and priority. 4. Plan to complete care on each client in order according to the level of accuity.

3 If the nurse has additional personnel to assist with client care, the personnel must be used in the most efficient manner possible. Assigning routine care to both the NAP and LPN/LVN may not be the best use of each members' scope of practice. The LPN/LVN can be utilized to take additional responsibility, such as dressing changes and/or passing out medications. It is not always possible for the charge nurse to assign additional personnel to assist the nurse with client care. The nurse needs to utilize the skill of effective time management. CORRECT - The best way to manage a client workload effectively is for the nurse to identify the status of each client and plan care based on needs and priority. The nurse knows that both needs and priority must be considered. Basic needs are not the care priority if another client has a life-threatening or emergency situation. The nurse knows that the client with the highest acuity is not always the client who is a priority. Consider the high acuity of a comatose client and the high priority of a client experiencing a myocardial infarction. Completing client care on each client in order according to the level of acuity is not always an effective and/or efficient use of the nurse's time.

The nurse provides care for a number of clients in an acute care setting. Which client issues will prompt the nurse to follow up with the client's health care provider? (Select all that apply.) 1. A client who is 6 hours postoperative with an oral temperature of 100.7°F (38.2°C). 2. A client admitted from the ED following seizure activity, who is lethargic and sleepy. 3. A client who has a moderate amount of creamy red drainage on a surgical dressing. 4. A client with a cardiac disorder and a serum potassium level of 4.7 mEq/L (4.7 mmol/L). 5. A client with dehydration who has an hourly urinary output of 25 mL of dark amber urine.

3,5 A client who is 6 hours postoperative will have an elevated temperature from the body's response to surgical trauma. The temperature increase is expected and not elevated enough to require the nurse to follow up. After a client has a seizure, it is expected for the client to be lethargic and sleepy. The nurse will make sure that the client is on seizure precautions and safety needs are met. The nurse will not follow up with the health care provider. CORRECT - Creamy red drainage from a surgical site is indicative of an infection. The nurse will follow up with the the client's health care provider to report the finding and receive any new prescriptions. A client with a cardiac disorder has a normal serum potassium level of 4.7 mEq/L (4.7 mmol/L). There is no reason for the nurse to follow up on this client's laboratory report. CORRECT - A client who is dehydrated will be placed on strict I&O. The nurse notes an hourly output of 25 mL of dark amber urine and will recognize that follow up with the health care provider is necessary. The amount of urine is below the normal range (30 mL/hour). Therefore, the nurse needs to follow up with the health care provider. The dark color of the urine is expected with dehydration.

The visitor of one of your patients stops you in the hall and says, "I hope you will not try to revive my neighbor if her heart stops." The correct response is: 1. "That decision is up to the physician." 2. "We are all trained in CPR." 3. "I understand your concern, but I can't discuss your neighbor's care with you." 4. "There is a 'do-not-resuscitate" order in her medical record."

3. "I understand your concern, but I can't discuss your neighbor's care with you." Rationale: This response politely, yet firmly, informs the person inquiring about the patient that this is not a topic for discussion because doing so would constitute a major violation of your patient's privacy. Visitors may use this type of statement (which you may agree with) as a means of trying to get you to disclose information about their friend.

A patient had major surgery and says she is worried about what is happening at home, is worried about not being there to coach the soccer team tomorrow, is feeling pain, and wants to see her husband. Which action would you take first? 1. Tell her not to worry about things at home. 2. Allow her to call the children at home. 3. Administer pain medication. 4. Check to see who might be able to coach the soccer team. 5. Put in a call to her husband so she can obtain information and have him arrange for someone to coach the soccer team.

3. Administer pain medication.

You witness a nursing assistant force a patient who is trying to stand into a chair saying, "Don't keep trying to get up or I will restrain you." The nursing assistant's behavior is an example of: 1. Assault 2. Battery 3. Assault and battery 4. Negligence

3. Assault and battery Rationale: Assault is a threat to do bodily harm or to touch someone against their permission. Battery is unlawful physical contact. In the example, the assistant does both.

A student is deciding between different nursing educational programs for a future management role. Which would be the best choice? 1. Nurse practitioner program. 2. Associate degree nursing program. 3. Baccalaureate nursing program. 4. Practical/vocational nursing program.

3. Baccalaureate nursing program. Rationale: The Baccalaureate nursing program prepares the RN for a management role, although the ADN curriculum contains segments of management theory.

Which is an example of clinical judgment? 1. Weighing the pros and cons of which school to send your children to. 2. Deciding which nursing midterm examination to study for first. 3. Prioritizing which call light to answer first. 4. Answering the primary care provider's question in a diplomatic manner.

3. Prioritizing which call light to answer first. Rationale: Clinical judgment is critical thinking in the clinical setting. Although the first and second choices involve critical thinking, they do not occur in the clinical setting.

Which statement best describes health? Health is: 1. A relative state of being. 2. The total state of physical and psychological well-being. 3. The state of functioning well physically, mentally, and socially. 4. Being free of sickness or infirmity.

3. The state of functioning well physically, mentally, and socially.

The student neglects to raise the head of the bed of a patient receiving continuous tube feedings. The patient aspirates and develops pneumonia. Which correctly describes the student's liability in this situation? 1. The charge nurse is responsible because she did not delegate care appropriately. 2. The LPN caring for the patient is solely responsible because she is licensed. 3. The student is expected to provide the same standard of care as the LPN. 4. Both the nursing instructor and the student are equally liable.

3. The student is expected to provide the same standard of care as the LPN. Rationale: Though they may not be as fast or efficient as a licensed nurse, students caring for patients in the clinical setting are expected to perform all tasks and duties to which they are assigned at the level of the LPN.

The nurse evaluates the care provided to the patient by determining: 1. Whether she is beginning to improve 2. Whether all planned interventions were carried out 3. Whether expected outcomes have been achieved 4. Whether she is well enough for discharge

3. Whether expected outcomes have been achieved Rationale: Evaluation is performed by considering if the interventions have achieved the expected outcomes.

The nurse plans individualized care for a client diagnosed with morbid obesity. The nurse performs both physical and psychosocial assessments. Which client statement indicates to the nurse that the client requires additional education and support for the psychosocial aspects for weight loss? 1. "I need to be able to work and make a living for my children and spouse." 2. "I know that I have to lose weight because now I have some health issues." 3. "I have been unable to lose weight before because I don't know what to do." 4. "I am divorced and I am looking forward to losing weight and going on dates."

4 When the client can recognize realistic and important motivations for weight loss, the chances for success are better. The nurse will consider the client psychosocially motivated for the hard work of achieving and maintaining weight loss. When the client connects weight loss with concern about health issues, the nurse gains insight about what will motivate the client to lose weight. This statement indicates that the client is psychosocially motivated to lose weight and improve health. When the client admits a lack of knowledge about the process of losing weight, the nurse gains insight to what has prevented the client from losing weight in the past. The client's statement is an indication that the client is psychosocially ready to learn about weight loss. CORRECT - When the client is motivated to lose weight because of a divorce and the desire to regain a social life, the nurse becomes aware that the client may not be psychosocially ready to initiate or maintain weight loss. The client needs to understand relationships with others may not provide the motivation and support for weight loss.

When evaluating a patient admitted with a lower respiratory tract infection, which data are most important for the nurse to obtain? 1. Level of pain or discomfort 2. Medications taken at home 3. Duration of the illness 4. Bilateral lung sounds

4. Bilateral lung sounds Rationale: Auscultating the lung sounds to obtain data about the quality of air movement is the most important action for this patient with a respiratory infection.

Clinical reasoning is most important when: 1. Planning wound care for a pressure injury. 2. Organizing nursing care for several patients. 3. Collaborating with other health team members. 4. Drawing sound conclusions from assessment data.

4. Drawing sound conclusions from assessment data. Rationale: Although critical thinking skills may be used in any of the answer choices, the most comprehensive answer choice is #4, because drawing conclusions requires an analysis of data and synthesizing it.

One main difference between a licensed practical/vocational nurse and an RN is that the licensed practical/vocational nurse: 1. Usually is responsible for giving medications. 2. Performs only noninvasive procedures. 3. Cares for fewer patients than the RN. 4. Is required to work in a supervised setting.

4. Is required to work in a supervised setting.

It is important that the nurse understand that certain cultural traits should be assessed in patients. Patients of Asian, African, and Hispanic descent should be assessed for: 1. Stomach cancer 2. Retinopathy 3. Sickle cell anemia 4. Lactose intolerance

4. Lactose intolerance Rationale: Assess patients of Asian, African, and Hispanic descent for lactose intolerance because it is prevalent in people of those groups.

Common sympathetic reactions to a stressor that occurs suddenly include: (Select all that apply.) 1. Constriction of the pupils in the eyes. 2. Increase in saliva and tear production. 3. A "weak in the knees" feeling. 4. Pounding of the heart with rapid pulse. 5. Dilation of the pupils. 6. Increased blood pressure.

4. Pounding of the heart with rapid pulse. 5. Dilation of the pupils. 6. Increased blood pressure.

A patient who is 14 hours postoperative complains of shortness of breath. Which action should be implemented first? 1. Auscultate the lungs. 2. Question about previous shortness of breath. 3. Check for an order for oxygen therapy. 4. Reassure the patient.

4. Reassure the patient. Rationale: The patient should be reassured to prevent an increase in anxiety that could make the shortness of breath worse. Then the lungs would be auscultated and the medical record checked for an order for oxygen if breath sounds indicate the need.

Which statement correctly describes a nursing diagnosis when compared with a medical diagnosis? 1. Nursing diagnoses and medical diagnoses are essentially the same. 2. A nursing diagnosis supports a medical diagnosis. 3. Medical and nursing diagnoses are not related to one another. 4. The nursing diagnosis describes a patient response to the medical diagnosis.

4. The nursing diagnosis describes a patient response to the medical diagnosis. Rationale: A nursing diagnosis is a description, using specific taxonomy, of a patient's response (physiologically and/or psychologically) to a medical condition, any treatments, their life situation and their environment.

The effects of stress on a person partially depend on: 1. The presence of prior illness. 2. The time of day it occurs. 3. The surrounding environment. 4. The perception of the stressor.

4. The perception of the stressor.

What is the purpose of the initial health history and assessment? 1. To collect data about a specific health problem 2. To identify life-threatening problems 3. To compare current health status to baseline data 4. To establish a database to identify the patient's current health status

4. To establish a database to identify the patient's current health status. Rationale: The initial health history and assessment provides a database of information on the patient's health status at the time of admission. It is the baseline against which subsequent data will be compared.

Input from the __________________ during the planning stage of the nursing process results in greater success. (Fill in the blank.)

patient