Ch 10: Practicing for NCLEX

When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury? A. After the patient Feels comfortable in the clinical setting B. After the HCP has prescribed rehabilitative goals C. When an exercise program has been initiated D. With initial patient contact

D

A patient who has a disability is attempting to gain employment via vocational rehabilitation. What should the nurse closely monitor in the patient with a disability attempting to seek employment? A. Substance abuse B. Cognitive ability C. Orientation level D. Self-care ability

A

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk? A. Serum albumin B. Serum glucose C. PT time D. Sedimentation rate

A

A patient in rehabilitation has become dependent on family members' assistance with self-care. Which nursing actions will encourage the patient to become independent? SATA A. Motivate the patient to learn and accept responsibilities for self-care. B. Help the patient identify safe limits of independent activity. C. Educate the patient in how to perform self-care activities. D. Inform the patient that the family will continue to provide care is self-care is not performed. E. Have the patient placed in a long term care facility until self-care activities are performed independently.

A, B, C

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care? A. The HCP B. The patient C. The physical therapist D. The nurse

B

What position should be avoided when positioning a patient in bed in order to decrease incidence of musculoskeletal complications? A. Prone B. Semi-fowlers C. Side-lying D. Dorsal

B

The nurse determines the patient is at risk for the development of skin breakdown. Which nursing actions would be most effective as a preventative measure? A. Application of powder B. Insertion of an indwelling catheter C. Administration of vit B12 D. Practicing meticulous hygiene measures

D

The nurse is using a measurement tool to determine a patient's level of independence in ADL's such as continence, toileting, transfers, and ambulation. What would be the appropriate tool for the nurse to use? A. Barthel Index B. Patient evaluation conference system C. The PULSES profile D. The Braden Scale

A

The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding? A. Anoxia B. Escobar C. Hyperemia D. Ischemia

C

The nurse is fitting a patient for crutches that are required for an ankle injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height? A. Use the patient's height and add 6 in B .Use the patient's height and add 12 in C. Use the patient's height and subtract 8 in D. Use the patient's height and subtract 16 in

D

What diet can the nurse recommend to a patient with hypoproteinemia that spares protein? A. A diet high in carbohydrates B. A diet high in fats C. A diet high in minerals D. A diet high in vitamins

A

The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? SATA A. Set a daily defecation time that is within 15 min of the same time every day B. Have an adequate intake of fiber-containing foods C. Have a fluid intake between 2 and 4 L/Day D. Take a retention enema fault E. Take a laxative daily

A, B, C

The nurse is initiating a bladder training schedule for a patient. What interventions can be provided for optimal success? SATA A. Encourage the patient to wait 30 min after drinking a measured amount of fluid before attempting to void B. Give up to 3000 mL of fluid daily C. Teach bladder massage to increase intra-abdominal pressure. D. Require the patient to restrict fluid intake during the day to decrease voiding. E. Give a diuretic every morning

A, B, C

The nurse is assisting a patient in assuming a side-lying position. Which intervention would be best for the nurse to provide? A. Align the lower extremities in a neutral position B. Extend the legs with a firm support under the popliteal area C. Place the uppermost hip slightly forward in a position of slight abduction D. Position the trunk so that hip flexion is minimized

C