Pearson NCLEX Prep

Pearson NCLEX Prep Leave the first rating Students also studied Terms in this set (14) Science MedicineNursing Save NCLEX Question Bank with Rational...77 terms Haley_Malzac Preview PEARSON NCLEX-RN Questions & R...199 terms Candice_Haygood Preview bootcamp test 1 readiness 77 terms heather92powers Preview Prioritiz 28 terms mad An individual falls and fractures a hip while walking down the street. A companion notices a nurse drive past without stopping to assist. The individual sues the nurse for negligence but fails to win a judgment for which reason?The nurse had no duty to the individual.The nurse did what most nurses would do in the same circumstance.The nurse did not cause the client's injuries.The nurse was off-duty at that time.The nurse had no duty to the individual.

Explanation:

To be guilty of negligence, the nurse must have a relationship with the client that involves a duty to provide care. The relationship is usually a component of employment. The nurse did not necessarily do what others would do in this situation. Although the nurse did not cause the client's injuries, it does not prevent the nurse from assisting in this situation. Although the nurse was off-duty, the nurse could have assisted if motivated to do so.An unlicensed care provider (UCP) is assigned to a care area. Which activity should the nurse complete before delegating tasks to this caregiver?Determine UCP competency to perform the task Provide UCP with written directions Ensure all supplies are at the clients' bedsides Inform clients that UCP will be providing care Determine UCP competency to perform the task

Explanation:

Safe and effective delegation is based on knowledge of the laws governing nursing practice and knowledge about job duties and responsibilities. Nurses must understand the competencies and training of unlicensed care providers. It is not necessary to provide written directions when delegating tasks to UCPs as long as verbal directions are clear and expectations are understood. UCPs can deliver supplies to the client's bedside and this is not a priority consideration of the nurse. UCPs are part of the care delivery team and do not require a special introduction. UCPs can introduce themselves to clients. Cognitive Level: Applying Client Need: Management of Care Integrated Process: Nursing Process: Implementation Content Area: Leadership and Management Strategy: Use knowledge of the five rights of delegation to answer the question. In this case, consider the competence of the UAP as integral to the question

The nurse has applied elbow splints on a confused client to prevent the client from removing the intravenous (IV) line. Which of the following interventions is required?Document appearance of client's IV site every hour Remove elbow splints every 8 hours Ask for renewal of prescription for restraint every 72 hours Assess and document client's condition at least every hour Assess and document client's condition at least every hour

Explanation:

The client should be checked at least hourly, and the nurse must document client status. Physical restraints impede a client's freedom; their use needs to be prescribed every 24 hours. Because restraints may impede circulation, they should be removed according to agency policy, which is generally every 1-2 hours rather than every 8 hours. The IV site should be checked every hour, but documentation may be done only once per shift unless a problem occurs.The nurse assesses the temperature and blood pressure of a client on contact precautions every shift because of wound infection. What action should the nurse take to minimize the spread of microorganisms?Keep the equipment in the client's room Store the equipment in the soiled utility room between uses Cleanse the equipment after each use No special action is required with the equipment Keep the equipment in the client's room

Explanation:

Equipment for client care is dedicated to the client on contact precautions and is kept in the client's room. The equipment should not be stored in the soiled utility room between uses because it could contain surface microorganisms that could come in contact with personnel. Cleansing the equipment after each use is not practical; it would be more efficient to keep the equipment in the client's room.The equipment does require special action to prevent transmission of infection.The client, a 16-year-old female, has come to the clinic for contraception after recently becoming sexually active. The client states that several friends use spermicides and asks about their advantages and disadvantages. What is the nurse's best response?"If you want an effective method, you should choose something else." "It is a very convenient method to use overall and you will be able to insert the spermicide up to 4 hours before intercourse." "Spermicides cause very few problems for the majority of people, and they are almost 100 ?fective." "Spermicides may or may not be a good choice; they have a failure rate of about 21 % and offer some protection against sexually transmitted infections." "Spermicides may or may not be a good choice; they have a failure rate of about 21 % and offer some protection against sexually transmitted infections."

Explanation:

Spermicides must be used within 30 minutes of intercourse, have a failure rate of 21%, and do offer some protection against sexually transmitted infections. Other key information needed is the sexual history of the client and her partner(s) to more accurately assess risk for STIs. The nurse should not provide advice to the client.

The client, who is a primigravida, has come to the clinic for a scheduled prenatal visit. She expresses concern about facial chloasma that has developed since her last prenatal visit. What is the best response by the nurse?"You should apply a facial skin bleach twice a day." "Avoiding sun exposure may keep the pigmentation from getting any darker." "This is a permanent condition caused by hormonal changes. You may be able to cover it with makeup." "This is a condition associated with the development of skin cancer. I will make an appointment for you with a dermatologist." "Avoiding sun exposure may keep the pigmentation from getting any darker."

Explanation:

Increased pigmentation during pregnancy is a response to increased estrogen levels. It generally fades after the pregnancy ends and the use of facial skin bleach is not needed. Increased pigmentation during pregnancy is a response to increased estrogen levels. It can be worsened by the sun. Increased pigmentation during pregnancy is a response to increased estrogen levels, and generally fades after the pregnancy ends. Increased pigmentation during pregnancy is a response to increased estrogen levels during pregnancy. It is not associated with cancer.The nurse would use which intervention as the most accurate method to assess the frequency, duration, and strength of contractions of a woman in active labor?Abdominal palpation Tocodynamometer Intrauterine pressure catheter (IUPC) Client's description Intrauterine pressure catheter (IUPC)

Explanation:

Abdominal palpation will give limited information about uterine contractions, especially if the client is either very thin or obese. The tocodynamometer, or external uterine transducer, will detect the onset and end of contractions in most women but does not assess intensity of the contractions. Additionally, if the client is either very thin or obese, the fetal monitor tracing will either exaggerate the contractions or minimize them. Internal contraction monitoring through the use of an intrauterine pressure catheter will objectively measure the contractions in mm of Hg and is the most accurate method of contraction monitoring. The client's description of the contractions will be influenced by her culturally based expression of pain as well as by her previous pain experiences and pain threshold.Although a client initially wanted to breast-feed, she has now decided to bottle-feed her newborn with formula.The nurse concludes that teaching regarding breast care for this client has been effective when the client makes which statement?"I'll pump 2-3 times each day until my milk supply decreases." "I'll rub lotion on my breasts if they are sore." "I'll soak my breasts in a warm tub twice daily for the first week." "I'll wear a snug bra continuously until my breasts are soft again." "I'll wear a snug bra continuously until my breasts are soft again."

Explanation:

Pumping the breasts is a form of breast stimulation that should be avoided.Applying lotion to the breast is a form of breast stimulation that should be avoided. Applying heat via a warm bath will stimulate the breasts and should not be done. Mothers who are bottle-feeding should be encouraged to suppress milk production by wearing a snug bra or breast binder, applying cold compresses, and avoiding breast stimulation until primary engorgement subsides.The nurse observes that when a newborn is supine and the head is turned to one side, the extremities straighten to that side while the opposite extremities flex. How should the nurse document this finding?Tonic neck reflex Moro reflex Cremasteric reflex Babinski reflex Tonic neck reflex

Explanation:

The tonic neck reflex, or fencing position, refers to the position the newborn assumes when supine with the head turned to one side. The extremities on that side will extend, and the extremities on the opposite side will flex. The Moro reflex occurs when the newborn is startled and responds by abducting and extending arms, with fingers fanning out and the arms forming a "C." The cremasteric reflex refers to retraction of the testes when chilled, or when the inner thigh is stroked.The Babinski reflex refers to the flaring of the toes when the sole of the foot is stroked upward.

An inexperienced mother is playing with her 8-month-old in the playroom. The nurse has taught the mother about toys that are developmentally appropriate for the child.The nurse will conclude that teaching has been successful when the mother selects which type of toy?Select all that apply.?A set of blocks A wagon A puzzle with large pieces A rattle A soft ball A set of blocks A soft ball

Explanation:

Objects that can be grasped and banged together, such as blocks, develop manipulation skills and are most appropriate for an 8-month-old infant. Pleasure is experienced from the feel and sounds of these activities. A wagon may be used by preschoolers and toddlers. A large-piece puzzle may be used by preschoolers and toddlers. Rattles are recommended for infants ages 1 to 6 months.The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine and a second inactivated polio vaccine (IPV) vaccine for an infant who is 4 months old. Provided a separate injection site is used for all injections, the nurse also may give which immunization during this well-child visit?Varicella (Varivax) Influenza (TIV) Measles, mumps, and rubella (MMR) Haemophilus influenzae type B (Hib) Haemophilus influenzae type B (Hib)

Explanation:

Varicella is given at 12-18 months or anytime up to 12 years (one dose), and to children 13 years and older (two doses, 4-8 weeks apart). Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12-15 months and 4-6 years of age (two doses). Haemophilus influenzae type B (HIB) vaccine is given at 2, 4, 6, and 12-15 months of age (four doses).When asking a client newly admitted to the hospital about dietary history, which question by the nurse would be most important?"What time of day do you eat each meal?" "Do you eat alone or with family members?" "How often do you eat meals at restaurants?" "Do you have any dietary restrictions?" "Do you have any dietary restrictions?"

Explanation:

The timing of client meals may be of interest, but meal times in hospitals are based on a unit schedule, not client preference. Asking about whether a client eats alone or with others provides data about family or other dynamics, but is not the priority at this time. The frequency of dining in restaurants may become important if the nurse conducts dietary teaching with the client. Noting dietaryrestrictions based on a medical condition (e.g., low-sodium for heart disease), food allergies or religious convictions (e.g., abstaining from pork if Jewish or Muslim) helps to provide safe and appropriate care for the client.While a client with cancer is hospitalized for radiation therapy, the client asks the nurse about the use of mind- body therapies to aid in pain management. What options would be appropriate for the nurse to suggest?Select all that apply.Progressive relaxation Acupuncture Yoga Chiropractic medicine Guided imagery Progressive relaxation Guided imagery

Explanation:

The client with cancer who has pain may benefit from progressive relaxation.Acupuncture is not used in hospital settings, since healthcare providers usually direct the prescription for treatments.Yoga is not used in hospital settings, since healthcare providers usually direct the prescription for treatments.Chiropractic practices are not used in hospital settings, since healthcare providers usually direct the prescription for treatments.The client with cancer who has pain may benefit from guided imagery.