NCLEX questions me chapter 4

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time would respond with which question or statement?

"Are you fearful and think that others may want to hurt you?"3

The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document which findings as a normal FHR pattern?

150 beats per minute, moderate variability3

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift

The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse would perform which?

Lower the voice pitch and face the client when speaking. Submit

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse would expect to document that the fundus of the uterus is located at which area?

Midway between the symphysis pubis and the umbilicus Submit

Which actions would be performed when communicating with a client with presbycusis? Select all that apply.

speak slowly face client when speaking use short sentence and phrases

The nurse manager asks a licensed practical nurse to work on her day off because of a short-staffing problem. The licensed practical nurse has already made plans and does not want to work on the day scheduled to be off. Which response by the licensed practical nurse to the nurse manager is assertive?

"I have planned to take the day off and will not be able to work on that day."

While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse would be therapeutic?

"So you're saying that you want to talk to your primary health care provider?"4

While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response?

"You don't think you can ever do anything right?"3

The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client?

Completing the sentences that the client cannot finish4

Which guidelines would the nurse follow when performing narrative documentation? Select all that apply.

Date and time entries.2 Sign and title each entry.3 Avoid judgmental and evaluative statements.4 Do not leave blank spaces on documentation forms. Submit

The licensed practical nurse (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 (PHCP) 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.4

A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate?

"Tell me what concerns you have."

The nurse is caring for a client with left-sided heart failure. Which clinical signs are most important for the nurse to communicate to the primary health care provider? Select all that apply.

Pink-tinged frothy sputum Increase in respiratory rate Auscultation of crackles throughout the lungs

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which action should the nurse take?

Seek an interpreter from the hospital's interpreter services.4

A 10-year-old child in remission from leukemia is upset over the appearance of cushingoid characteristics from long-term use of corticosteroids that are currently being administered every other day. Which therapeutic statements would the nurse make to the child about the cushingoid appearance? Select all that apply.

Which manifestations of this condition do you find most troublesome?" The signs/symptoms are lessened by taking the prednisone every other day instead of daily." The cushingoid appearance will gradually disappear once the steroids are tapered and discontinued."

A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response?

You are concerned about losing your leg?"

The student nurse is being taught by the registered nurse (RN) how to collect data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the student nurse indicates a need for further teaching?

I am the nurse and, as such, I'll have you know that all information is kept confidential."

A family has brought a toddler to the emergency department with a fractured arm. The nurse knows that nonverbal communication is important to evaluate with assessing the family. Which factors are involved in nonverbal communication? Select all that apply.

touch body posture use of space eye contact