NCLEX Practice Questions and Answers with complete solutions

NCLEX Practice Questions and Answers with complete solutions A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment with carbamazepine (Tegretol) is being transferred in stable condition from the intensive care unit to the medical unit. There are 4 beds available. The nurse knows the best choice of roommates for this client is which of the following? (a) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA). (b) A 28-year-old woman diagnosed with diarrhea. (c) A 72-year-old man with fever of unknown origin. (d) A 68-year-old woman with atrial fibrillation . - ANS- Correct answer: (d) A 68-year-old woman with atrial fibrillation. Rationale: A client with Stevens-Johnson syndrome is likely to have severe skin integrity issues, including blistering and skin shedding, which can place the client at high risk for infection. Atrial fibrillation is not an infectious process. All other patients may be an infection risk for an individual with altered skin integrity. A 72-year-old man who had a stroke is being transferred from a medical unit to a rehabilitation centre. The nurse case manager is assisting in the process. The nurse knows that the goals of case management include which of the following? Select all that apply. (a) Improving the coordination of care (b) Increasing referrals to local organizations (c) Reducing the fragmentation of care (d) Discharging clients quickly - ANS- Correct answer: (a) Improving the coordination of care; and (c) Reducing the fragmentation of care Rationale: Some of the primary goals of case management are to improve the coordination of care and to reduce fragmentation of care. The other options are not goals of case management. A nursing team consists of an RN, an LPN/ LVN, and a nursing assistant. The nurse should assign which of the following patients to the LPN/LVN? (a) A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer. (b) A 42-year-old patient with cancer of the bone complaining of pain. (c) A 55-year-old patient with terminal cancer being transferred to hospice home care. (d) A 23-year-old patient with a fracture of the right leg who asks to use the urinal. - ANS- Correct answer: (a) A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer. Rationale: LPN/LVNs assist with implementation of care; performs procedures; differentiates normal from abnormal; cares for stable patients with predictable conditions; has knowledge of asepsis and dressing changes; administers medications. Patient (a) is stable with an expected outcome. Patients (b) and (c) require assessment and nursing judgement; and Patient (d) involves a standard unchanging procedure that can be assigned to the nursing assistant. A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the client is being prepped for the procedure, it becomes clear to the nurse that the client doesn't fully understand the risks and benefits associated with the procedure. Which of the following describe the nurse's role in obtaining informed consent? Select all that apply. (a) Explain the risks and benefits associated with the procedure. (b) Describe alternatives to the procedure. (c) Witness the client's signature on the consent form. (d) Advocate for the client by ensuring she is making an informed decision. - ANS- Correct answer: (c) Witness the client's signature on the consent form; and (d) Advocate for the client by ensuring she is making an informed decision. Rationale: Some of the nurse's roles in the informed consent process are to witness the signature on the consent form, and to advocate for the client by ensuring she has been provided the necessary information to make an informed decision. It is the physician's duty to provide information to the client-related risks and benefits, and to provide alternatives. A registered nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? (a) A client requiring colostomy irrigation (b) A client receiving continuous tube feedings (c) A client who requires stool specimen collections (d) A client who has difficulty swallowing food and fluids - ANS- Correct answer: (c) A client who requires stool specimen collections Rationale: This question addresses content related to delegation in the subcategory Management of Care in the Client Needs category of Safe and Effective Care Environment. Work that is delegated to others must be done consistent with the individual's level of expertise and licensure or lack of licensure. In this situation, the most appropriate assignment for the nursing assistant is to care for the client who requires stool specimen collections. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration. Remember, the health care provider needs to be competent and skilled to perform the assigned task or activity. A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices a staff member who is not involved in the client's care reading his medical record. The nurse knows she should FIRST do which of the following? (a) Nothing. The staff member has a hospital ID badge and is authorized to read the medical record. (b) Inform the staff member that without a legitimate need for the information, staff should not be reading the medical record. (c) Tell the client his medical records have been read by an unauthorized individual. (d) Page the physician and ask if it's acceptable for the staff member to access the medical records. - ANS- Correct answer: (b) Inform the staff member that without a legitimate need for the information, staff should not be reading the medical record. Rationale: An individual not involved in the care of the client does not have a legitimate need to access the medical record. The nurse should protect the client's right to privacy by ensuring only authorized individuals access medical records. After receiving report at the start of the evening shift, which of the following clients should the nurse attend to first? (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L. (b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10. (c) A 55-year-old woman with ovarian cancer waiting to be discharged. (d) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse oximetry of 96% on room air. - ANS- Correct answer: (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L. Rationale: Hyperkalemia is a potentially serious condition that, in a client undergoing treatment for non-Hodgkin lymphoma, could indicate tumour lysis syndrome. Patient (b) should be attended to, but her condition is not as urgent. Patients (c) and (d) do not require immediate attention. The nurse in a maternity unit is caring for a client who has just delivered twins. The client voices concern about her ability to manage when she gets home. Which of the following statements best illustrates quality care delivery by the nurse? Select all that apply. (a) "Just focus on how lucky you are to have two healthy babies." (b) "We can arrange for follow-up visits with a home health nurse." (c) "Here is some information on support groups for parents of multiples."