SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE

SAUNDERS_COMPREHENSIVE_REVIEW_FOR_NCLEX_ONE.doc 1) The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continu ...

SAUNDERS_COMPREHENSIVE_REVIEW_FOR_NCLEX_ONE.doc 1) 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. 1) 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. 2) 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 3) The nurse is preparing a plan of care for a 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." 4) 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? Answers-Reflecting a cultural value 5) When communicating with a client who speaks a different language, which best practice should the nurse implement?  Arrange for an interpreter to translate. 6) The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which most appropriate response?  Answers-"A person who moves from China to the United States (U.S.) and learns about and adapts ato the culture in the U.S." 7) An Asin American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method?  Foods considered to be yin 8) Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?  Sweet and sour chicken with rice and vegetables, mixed fruit, juice. 9) Which is the best nursing intervention regarding complementary and alternative medicine?  Educating the client about therapies that he or she is using or is interested in using 10) 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? Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). 11) 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." 12) 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. 13) 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 for the surgical procedure, which is the best action?  Transport the victim to the operating room for surgery. 14) The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? Reassess the client. 15) 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. 16) 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. 17) 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." 19) The nurse has made an error in a narrative documentation of an assessment finding on a client 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.20) Which identifies accurate nursing documentation notations? Select all that apply.  The client slept through the night.  Abdominal wound dressing is dry and intact without drainage.  The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. 21) A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?  Observing care provided to the client without the client's permission 22) Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort?  Slander 23) 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? 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." 24) 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. 25) 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. 26) 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 27) The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?  A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 28) A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursingmodel 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. 29) 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 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C) 30) 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. 31) The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed 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.32) The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)?  A client who requires urine specimen collections 33) The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.  Move beds away from windows.  Close window shades and curtains.  Place blankets over clients who are confined to bed. 34) The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse?  A client requiring abdominal wound irrigations and dressing changes every 3 hours 35) 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 36) 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 additionalmanifestations would the nurse expect to note in this client if excess fluid volume is present?  An increase in blood pressure and increased respirations 37) 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 38) 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 39) 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 during administration.  Monitor the IV site for signs of infiltration or phlebitis.  Ensure that the medication is diluted in the appropriate volume of fluid