Details of NURSING Med Surg 2 SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE
1) The nurse is providing discharge instructions to a Chinese American client
... [Show More] 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. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.
40)
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 [Show Less]