NGN NCLEX RN ACTUAL Exam V2

NGN NCLEX RN ACTUAL Exam V2

• during a discussion about a living will w/ a 75yr old client & the client's

son, the son says, "I do not understand the need for a living will." which of these statements would be accurate & appropriate for the nurse to say in a

response to this question?:

Answer:

"health care decisions can be made based on the client's wishes"

• the nurse is assessing the client during a home health visit & the client

states: "i had PT yesterday. I thought it was supposed to help but my back

hurts so much after each visit." the nurse's responsibility include which of the

following actions? select all that apply:

Answer:

=report the client's finding to the nursing supervisor for further assessment.=report the client's findings to the PT =gather more info about the location, duration, intensity of the pain

• an 80yr old client is hospitalized for a chronic condition. the cleint informs

family members that a living will has been prepared & the client wants no life prolonging measures performed. the client's condition deteriorates & the client becomes unresponsive. which of the following nurisng actions is most

appropriate?/:

Answer:

notify the attending physician =the first action would be notify physician for further orders. then the familymembers can be contacted about his condition. when a client has an adavanced directive, it is NOT appropriate to perform CPR on him.

• a client w/ Dx of bipolar disorder has been referred to a halfway house

to be considered for placement. a social worker telephones the hospital unit & asks for info about the client's mental status & adjustment. what must the

nurse understand in order to respond to this request for info??:

Answer:

info can be released if there is written consent from the client.

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• during a discussion w/ the nurse manager, a staff nurse confides that she

is attracted to a client regularly assigned to her. which of the following actions

should be implemented following this discussion?:

Answer:

the nurse transfers the care of the client to another nurse.

• the nurse is using SBAR technique to communicate w/ the HCP. which of

the following phrases would be associated w/ "B-background"?:

Answer:

"the cleint's Tx are..." the HCP background info about the client includes: age, primary Dx, Tx, etc. stating that the clients condition is deteriorating is the situation (S). stating, "I would like you to..." is the request or recommendation (R).V/S are part of the assessment (A).

• the child is newly Dx w/ Hepatitis A. which teaching instructions would

the nurse reinforce w/ the child's parents?:

Answer:

wash hands thoroughly w/ soap &warm water after contact w/ the child.=spread through contaminated food or water, unsanitary conditions in childcare facilities or schools. the infection resolves spontaneously & symptoms relief is usually the only Tx. the child oes not have to be confined to bed s/he can safely return to daycare or school one wk after symptoms began. infants & young children usually do not develop jaundice.

• the client is Dx w/ active TB & the case has been reported to the health

department. what is the most important reason for notifying the health

department?:

Answer:

contacts need to be traced & screened.=active TB is a reportable disease bc people who had contact w/ the client must be traced, evaluated for the disease, & possibly treated prophylactically. statistics are kept & trends documented, but that is not the primary reason for required reporting.

• at 3month, the infants has cleft ip & soft palate repair. in the immediate

pos-op period for a cleft lipp repair, which action is the priority?:

Answer:

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remove soft elbow/arm restraints q2hr under supervision.

• an outpt. client is scheduled to recieve on oral solution of radioactive

iodine. in order to reduce hazards, the PN should reinforce which info?:

Answer:

Urine & saliva will be radioactive for 24hr after ingestion.

• fall prevention involves managing a client's underlying fall risk factors &

then implementing strategies to reduce falls. using restraints, including side rails, can actually increase the risk of fall-related injuries & deaths. clients w/ dementia cannot process the info we provide when we attempt to reorient

them to our reality.:

Answer:

true

• A nurse is stuck in the hand by an exposed needle left in a client's

bed linens. what immediate action should the nurse take?:

Answer:

immediately wash hands w/ vigor.=it will help remove the contaminate. then, the sequence of actions would be options "notify," "look up" & "contact"

• Abrupt, high-pitched snapping

noise: Answer: heart murmur

• is normal and represent the S1 (first heart sound) and S2 (second heart sound):

Answer:

Lubb-dubb sounds

15. is described as a scratchy, leathery heart sound:

Answer:

pericardial friction rub

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