Saunders Comprehensive NCLEX-RN Exam Review: UNIT 2 Professional Standards in Nursing. In 113 Page contains Ch 5, 6 and 7 with Practice Questions, Answers and Rationale.

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THIS DOCUMENT CONTAINS: C H A P T E R 5: Care of Special Populations C H A P T E R 6: Ethical and Legal Issues C H A P T E R 7: Prioritizing Client Care: Leadership, Delegation, and Emergenc... y Response Planning Practice Questions 1. Which teaching method is most effective when providing instruction to members of special populations? 1. Teach-back 2. Video instruction 3. Written materials 4. Verbal explanation 2. Which health concern(s) should the nurse be aware of as risk factors when caring for clients of African American descent? Select all that apply. 1. Cancer 2. Obesity 3. Hypertension 4. Heart disease 5. Hypothyroidism 6. Diabetes mellitus 3. The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes information about which measure that is related to a newborn complication within this ethnic group? 1. Safe sleeping 2. Car seat safety 3. Breast-feeding 4. Baby-proofing 4. The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk? 1. Lesbian persons 2. Men-who-have-sex-with-men (MSM) 3. Women-who-have-sex-with-women (WSW) 1434. Female-to-male (FTM) transgender persons 5. Which therapeutic communication technique is most helpful when working with transgender persons? 1. Using open-ended questions 2. Using their first name to address them 3. Using pronouns associated with birth sex 4. Anticipating the client’s needs and making suggestions 6. Which special population should be targeted for breast cancer screening by way of mammography? Select all that apply. 1. Male-to-female (MTF) 2. Female-to-male (FTM) 3. Men-who-have-sex-with-men (MSM) 4. Women-who-have-sex-with-men (WSM) 5. Women-who-have-sex-with-women (WSW) 7. The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first? 1. Blood pressure 154/72 mm Hg 2. Visual acuity of 20/200 in both eyes 3. Random blood glucose level of 206 mg/dL (11.47 mmol/L) 4. Complaints of pain associated with numbness and tingling in both feet 8. The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed? 1. Glipizide 2. Lisinopril 3. Metformin 4. Beclomethasone 9. The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete? 1. The history 2. The physical assessment 3. The nursing plan of care 4. The readmission risk assessment 10. The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond? 1. “Health care is very limited in the prison setting.” 2. “Living in a prison isn’t different than living at home.” 3. “Living in a prison can predispose a person to different health conditions.” 4. “Living in a prison is similar to living in a condominium complex or dormitory.” 14411. The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up? 1. Reddened sclera of the eyes 2. Dry flaking noted on the scalp 3. A reddish-purple mark on the neck 4. A scaly rash noted on the elbows and knees 12. The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply. 1. Asthma 2. Claustrophobia 3. Sleep problems 4. Bipolar disorder 5. Aggressive behavior 6. Attention-deficit hyperactivity disorder (ADHD) 13. The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? 1. Hypertension 2. Hyperlipidemia 3. Substance abuse disorder 4. Post-traumatic stress disorder 14. The nurse caring for a refugee considers which health care need a priority for this client? 1. Access to housing 2. Access to clean water 3. Access to transportation 4. Access to mental health care services 15. Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? 1. Arranging for home health care 2. Focusing on managing a single illness at a time 3. Communicating with one provider only to avoid confusion for the client 4. Allowing the client t Practice Questions 16. 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 primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed. 17. 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? 1. Obtain a court order for the surgical procedure. 2. Ask the EMS team to sign the informed consent. 3. Transport the victim to the operating room for surgery. 4. Call the police to identify the client and locate the family. 18. The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Contact the nursing supervisor to update information regarding the fall. 4. Document in the nurse’s notes that an occurrence report was completed. 19. 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? 1. Refuse to float to the ICU based on lack of unit orientation. 2. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. 3. Ask the nursing supervisor to review the hospital policy on floating. 4. Submit a written protest to nursing administration, and then call the hospital lawyer. 20. The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker 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? 1. Call security. 2. Call the police. 1793. Call the nursing supervisor. 4. Lock the coworker in the medication room until help is obtained. 21. 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? 1. “I will sign as a witness to your signature.” 2. “You will need to find a witness on your own.” 3. “Whoever is available at the time will sign as a witness for you.” 4. “I will call the nursing supervisor to seek assistance regarding your request.” 22. The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client’s record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply. 1. Complete and file an occurrence report. 2. Right-click on the entry and modify it to reflect the correct information. 3. Document the correct information and end with the nurse’s signature and title. 4. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5. Document in a nurse’s note in the client’s record detailing the corrected information. 23. Which identifies accurate nursing documentation notation(s)? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client’s left lower medial leg wound is 3 cm in length without redness, drainage, or edema. 24. A nursing instructor delivers a lecture to nursing students regarding the issue of clients’ rights and asks a nursing student to identify a situation that 180represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Performing a procedure without consent 2. Threatening to give a client a medication 3. Telling the client that he or she cannot leave the hospital 4. Observing care provided to the client without the client’s permission 25. Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) 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 AP that making this accusation has violated which legal tort? 1. Libel 2. Slander 3. Assault 4. Negligence 26. An older 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? 1. “Oh, really? I will discuss this situation with your son.” 2. “Let’s talk about the ways you can manage your time to prevent this from happening.” 3. “Do you have any friends who can help you out until you resolve these important issues with your son?” 4. “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.” 27. The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? 1. Contact the nursing supervisor. 2. Administer the dose prescribed. 3. Hold the medication until the PHCP can be contacted. 4. Administer the recommended dose until the PHCP can be located. 28. 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? 1. Call the police. 2. Cut up the photograph and throw it away. 3. Call the nursing supervisor and report the occurrence. 1814. Call the laboratory and ask for the name of the individual who sent the photograp Practice Questions 29. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift 22030. 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? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 31. 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 nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the client’s needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). 4. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients. 32. 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? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutchwalking session 4. A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C 33. The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) 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? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the AP to find out when the last pain medication was given to the client. 3. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 34. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) 221is 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 AP? 1. Ignore the resistance. 2. Exert coercion on the AP. 3. Provide a positive reward system for the AP. 4. Confront the AP to encourage verbalization of feelings regarding the change. 35. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids 36. 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. 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hallways back into their rooms. 37. 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 nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly vital sign measurements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours 38. 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. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers’ needs and abilities [Show More]

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