NCLEX QUESTIONS POST TO BLACK BOARD FOR STUDENTS TO READ AND ANSWER

NCLEX QUESTIONS POST TO BLACK BOARD FOR STUDENTS TO READ AND ANSWER

ANSWERS AND RATIONALES

The nurse is planning to perform a physical assessment on an adult client. Prior to the assessment, which should be the nurse's first action?

• Provide a gown for the client to change into.
• Explain to the client what will happen during the examination.
• Obtain a written consent.
• Wash hands in the presence of the client.

Answer: 2

Explanation:

• The client may need to change into a gown in order for the nurse to perform the assessment;

however, the nurse should first explain what will be happening before asking the client to change clothing.

• The first thing the nurse should do prior to beginning the physical assessment of a client is

explain to the client what is about to happen. This helps to relieve a client's anxiety and enlists the client's cooperation with the assessment.

• Obtaining a written consent is not necessary, unless an invasive procedure will be performed.
• Handwashing should be performed just before the nurse begins to touch the client and after

a full explanation of the process is given and again at the completion of the physical assessment.

Page Ref: 92

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Therapeutic Communication

Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.

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The nurse is preparing a client for a detailed assessment of the integumentary system. Which Instruction should the nurse provide the client? Select all that apply.

• "Please remove all jewelry so that I can conduct a full assessment."
• "I will turn the temperature down in the exam room before we begin."
• "Use this blanket to cover up until we are ready to begin."
• "I will be touching your skin as part of the process."
• "I will need you to take off your head dress for the entire examination."

Answer: 1, 3, 4

Explanation:

• Jewelry can often hinder the nurse's ability to conduct a complete skin assessment. This

statement is appropriate to prepare the client for the exam.

2.The temperature of the room should be warm, yet comfortable. Turning down the temperature without first asking the client's input is not appropriate.

3.It is often necessary to expose certain areas of the skin during the assessment process. A drape should be provided to the client to cover all areas that are not being assessed. This action is appropriate prior to beginning the exam.

4.Palpating the skin is part of an integumentary assessment. It is important to state this to the client before the examination. This statement is appropriate to prepare the client for the exam.

• While it may be necessary for the client's head dress to be removed during certain portions of

the exam, it is not necessary for the entire examination process. This statement does not take the client's cultural background into consideration and is not appropriate.

Page Ref: 179

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population- based transcultural health assessments and interventions. | Nursing/Integrated Concepts:

Nursing Process: Assessment

Learning Outcome: 12.4: Outline the techniques for assessment of the skin, hair, and nails.MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.

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The nurse is preparing to perform a complete health assessment on a client. Which actions by the nurse are appropriate just prior to the examination? Select all that apply.

• Putting on nonsterile gloves.
• Providing an opportunity for the client to void.
• Washing hands in the presence of the client.
• Turning on soft music to relax the client.
• Ensuring adequate light in the room.

Answer: 2, 3, 5

Explanation:

• Gloves are needed only if the nurse may come into contact with the client's blood or body

fluids, such as during the assessment of the genitalia or anus.

• The client should be given an opportunity to void prior to physical assessment. This helps the

client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs.

• The nurse should always perform handwashing in the presence of the client prior to physical

contact. This demonstrates that the nurse is providing for the client's safety and also protects the nurse.

• The assessment should take place in a quiet environment in order for the nurse to correctly

identify sounds and their characteristics.

• The room should be brightly lit to facilitate good visibility.

Page Ref: 92

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice.MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment

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NURS-190-SPRING/

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