Download SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE 2022/2023 and more Exams Nursing in PDF only on Docsity!
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- The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action?
✓ Answers-Continue with the instructions, verifying client understanding.
- A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5)
✓ Answers-Ensures that a close relative stays with the client ✓ Makes a referral for a Catholic priest to visit the client ✓ Offers to provide a means for praying the rosary if the client wishes.
- Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5) ✓ Latino American Man ✓ Native American man ✓ Hispanic American man ✓ African American woman
- The nurse is preparing a plan of care for a
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client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? ✓ I cannot have any food containing or Prepared with blood."
- The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?
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regarding complementary and alternative medicine?
✓ Educating the client about therapies that he or she is using or is interested in using
- An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action?
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✓ Encourage the client to discuss the use of an herbal substance with the health care provider (HCP).
The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories? ✓ "Magnetic therapy and massage therapy are a focus of CAM."
The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?
✓ The client was found lying on the floor.
- A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent
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✓ Reassess the client.
- The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?
✓ Clarify with the team leader to make a safe ICU client assignment.
- The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
✓ Call the nursing supervisor.
- A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?
✓ "I will call the nursing supervisor to seek assistance regarding your request."
- The nurse has made an error in a narrative documentation of an assessment finding on a client
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and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply.
✓ Document the correct information and end with the nurse's signature and title.
✓ Draw 1 line through the error, initialing and dating it.
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tort?
✓ Slander
- An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?
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✓ As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."
- The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?
✓ Contact the nursing supervisor.
- The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?
✓ Call the nursing supervisor and report the incident.
- The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?
✓ A client with asthma who requested a breathing treatment during the previous shift
- The nurse employed in an emergency department is assigned to triage clients coming
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model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?
✓ An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients.
- The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?
✓ A client with a white blood cell count of 14,000 mm^3 (14.0 × 10^9 /L) and a temperature of 101°F (38.4°C)
The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? ✓ Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.
The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed
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assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP? ✓ Confront the UAP to encourage verbalization of feelings regarding the change.
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- The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.
✓ The acuity level of the clients ✓ Client needs and workers' needs and abilities
- The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional
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manifestations would the nurse expect to note in this client if excess fluid volume is present?
✓ An increase in blood pressure and increased respirations
- The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?
✓ Requires nasogastric suction
- The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.
✓ U waves
✓ Inverted T waves
✓ Depressed ST segment
- Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.
✓ Obtain an intravenous (IV) infusion pump.
✓ Monitor urine output
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✓ Ensure that the bag is labeled so that it reads the volume of potassium in the solution.
- The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.
✓ Raisins
✓ Potatoes
✓ Cantaloupe
✓ Strawberries
- The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.
✓ Peas
✓ Nuts
✓ Cauliflower
- The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
✓ Twitching
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- The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. ✓ Prolonged QT interval
✓ Prolonged ST segment
