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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.
- 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:
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
16. Vomiting will cause the loss of:
Answer:
hydrochloric acid and subsequent metabolic
- would occur in a child experiencing diarrhea because of the loss
of bicarbonate.:
Answer:
Metabolic acidosis
- An involves insertion of needle electrodes into selected
skeletal muscles to evaluate changes & electrical potential of the muscles & the nerves that lead to them. The test is useful in evaluating suspected lumbar or cervical disk disease, myasthenia gravis, muscular dystrophy, and other musculoskeletal diseases. The needle will not electrocute him or her, & will experience sensations comparable to an injection as the needles are inserted. An informed consent is required, & no other special
preparation is required for this test.:
Answer:
electromyogram
- The nurse is preparing a client for surgery. Which would be a
component of the plan of care?:
Answer:
Review the results of the preoperative laboratory studies.
- one of the most common skin infections among kids, usually
produces blisters or sores on the face, neck, hands, and diaper area. This contagious superficial skin infection is generally caused by one of two
bacteria:
Answer:
Staphylococcus aureus or Streptococcus pyogenes: impetigo
- a RN in a charge position is reinforcinbg goals to the health care team.
which of these itmes best decribes the goals of continous quality improvement
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