Saunders NCLEX-PN 7e
The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team based model of nursing practice? A: a task approach method is used to provide care to clients B: managed care concepts and tools are used when providing client care C: nursing staff are led by the nurse when providing care to a group of clients D: a single RN is responsible for providing nursing care to a group of clients
C: nursing staff are led by the nurse when providing care to a group of clients Rationale: A is functional nursing approach. B is a component of case management. C is a team nursing approach. D is primary nursing.
A client has died, and a nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. The nurse's appropriate action is to: A: Show acceptance of feelings. B: Provide information needed for decision making. C: Suggest a referral to a mental health professional. D: Remain with the family member without discussing funeral arrangements.
D: Remain with the family member without discussing funeral arrangements. Rationale: The family member is exhibiting the first stage of grief (denial) and the nurse should stay with them.
The nurse is recording a nursing hands-off (end of shift) report for a client. Which information needs to be included? A: as needed meds given that shift B: normal vital signs that have been normal since admission C: all of the tests and treatments the client has had since admission D: total number of scheduled meds that the client received on that shift
A: as needed meds given that shift Rationale: The end of shift report needs to be an efficient and accurate account of the client's condition during the last shift. It needs tests and treatments of the day, PRN meds or therapies preformed in the last 24 hours including the patient's response to them, changes in condition, upcoming tests and treatments, current problems, and concerns.
A nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness. Which is the appropriate nursing action? A: decline to sign the will B: sign the will as a witness to the signature only C: call the hospital lawyer before signing D: sign the will, clearly identifying credentials and employment agency
A: decline to sign the will Rationale: Living wills are required to be in writing and signed by the client. the client's signature either must be witnessed by specific individuals or notarized. Many states prohibit an employee from being a witness.
A nursing student is asked to identify the practices and beliefs of the Amish. Which should the student identify? SELECT ALL THAT APPLY: A: many choose not to have health insurance B: They believe that health is a gift from God C: the authority of women is equal to that of men D: they remain secluded and avoid helping others E: they use both traditional and alternative health care such as healers, herbs, and massage F: funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment.
A: many choose not to have health insurance B: They believe that health is a gift from God E: they use both traditional and alternative health care such as healers, herbs, and massage F: funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment. Rationale: The Amish society maintains a culture that is distinct and separate from non-Amish society. Family life has a patriarchal structure but roles of women and men are considered equal. Amish reject materialism and worldliness. They value living simply and may choose to avoid technology. They highly value responsibility, generosity, and helping others.
The nurse consults with a dietitian regarding the dietary preference of an Asian American client. Which food should the nurse suggest to include in the diet plan? A: rice B: fruits C: red meat D: fried foods
A: rice Rationale: Asian American food preferences usually include raw fish, rice, and soy sauce.
The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? SELECT ALL THAT APPLY: A: "An event is termed a mass casualty when it overwhelms local medical capabilities" B: "Mass casualty events do not require an increase in the number of staff that are needed." C: "a mass casualty event occurs only within the health care facility and could endanger staff." D: "Mass casualty events may require the collaboration of many local agencies to handle the situation" E: "a mass casualty event occurs if a fight between visitors occurs in the emergency department."
B: "Mass casualty events do not require an increase in the number of staff that are needed." C: "a mass casualty event occurs only within the health care facility and could endanger staff." E: "a mass casualty event occurs if a fight between visitors occurs in the emergency department." Rationale: mass casualty events: overwhelm local medical capabilities, require collaboration between agencies and hospitals, can occur in or out of a healthcare center, and almost always require an increase in staff
The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? A: A client in skeletal traction B: A client who is dependent on a ventilator C: a postop client preparing for discharge D: a client admitted during the previous shift with a diagnosis of gastroenteritis
B: A client who is dependent on a ventilator Rationale: Airway is always the priority.
The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider? A: garlic B: valerian C: lavender D: glucosamine
B: valerian Rationale: Valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous disorders such as anxiety
The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications? A: a 60 year old male client with rhinitis B: a 24 year old male client with a lower back injury C: a 10 year old female with a UTI D: a 45 year old female client with a history of migraine headaches
C: a 10 year old female with a UTI Rationale: children should not be given herbal therapies. especially in the home and without professional supervision. There are no general contraindications for the clients in A,B, or D. Subject: Chapter 5- Cultural Awareness and Health Practices
The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? A: a client complaining of muscle ache, headache, and malaise B: a client who twisted their ankle when they fell inline skating C: a client with a minor laceration on the index finger sustained while cutting an eggplant D: a client with chest pain who states that they just ate pizza that was made with a very spicy sauce
D: a client with chest pain who states that they just ate pizza that was made with a very spicy sauce Rationale: Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, acute neurological deficits, and those who sustained a chemical splash to they eyes are classified as emergent and number 1 priorities.
Which identifies accurate nursing documentation notations? SELECT ALL THAT APPLY: A: the client slept through the night B: abdominal wound dressing is dry and intact without drainage. C: the client seemed angry when awakened for vital sign measurement. D: the client appears to become anxious when it is time for respiratory treatments E: the client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
A: the client slept through the night B: abdominal wound dressing is dry and intact without drainage. E: the client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Rationale: Factual documentation contains descriptive objective information about what the nurse sees, hears, feels, or smells. Vague terms such as seems or appears are not acceptable because they suggest an opinion, not fact.
