SAUNDERS COMPREHENSIVE
REVIEW FOR NCLEX
The nurse is providing discharge instructions to a Chinese American client regarding
prescribed dietary modifications. During the teaching session, the client
continuously turns away from the nurse. The nurse should implement
which best action?
✓ Answers-Continue with the instructions, verifying
client understanding.
2) A critically ill Hispanic client tells the nurse through an interpreter that
she is Roman Catholic and firmly believes in the rituals and traditions
of the Catholic faith. Based on the client's statements, which actions by
the nurse demonstrate cultural sensitivity and spiritual support? Select
all that apply.(1,2,5)
✓ Answers-Ensures that a close relative stays with
the client
✓ Makes a referral for a Catholic priest to visit the client
✓ Offers to provide a means for praying the rosary if
the client wishes.
3) Which clients have a high risk of obesity and diabetes mellitus? Select
all that apply.(1,2,4,5)
• Latino American Man
• Native American man
• Hispanic American man
• African American woman
4) The nurse is preparing a plan of care for a client, and is asking the
client about religious preferences. The nurse considers the client's
religious preferences as being characteristic of a Jehovah's Witness if
which client statement is made?
✓ "I cannot have any food containing or
prepared with blood."
5) The ambulatory care nurse is discussing preoperative procedures with
a Japanese American client who is scheduled for surgery the following
week. During the discussion, the client continually smiles and nods the
head. How should the nurse interpret this nonverbal behavior?
✓ Answers-Reflecting a cultural value
6) When communicating with a client who speaks a different language,
which best practice should the nurse implement?
✓ Arrange for an interpreter to translate.
, 7) The nurse educator is providing in-service education to the nursing
staff regarding transcultural nursing care; a staff member asks the
nurse educator to provide an example of the concept of acculturation.
The nurse educator should make which most appropriate response?
✓ Answers-"A person who moves from China to the
United States (U.S.) and learns about and adapts ato the culture in
the U.S."
8) An Asin American client is experiencing a fever. The
nurse plans care so that the client can self-treat the disorder using which method?
✓ Foods considered to be yin
9) Which meal tray should the nurse deliver to a client
of Orthodox Judaism faith who follows a kosher diet?
✓ Sweet and sour chicken with rice and vegetables, mixed
fruit, juice.
10) Which is the best nursing intervention
regarding complementary and alternative medicine?
✓ Educating the client about therapies that he or she is using
or is interested in using
11) An antihypertensive medication has been prescribed for a client with hypertension.
The client tells the clinic nurse that he would like to take an herbal substance to help
lower his blood pressure. The nurse should take which action?
✓ Encourage the client to discuss the use of an herbal substance with
the health care provider (HCP).
12) The nurse educator asks a student to list the 5
main categories of complementary and alternative medicine (CAM), developed by the
National Center for Complementary and Alternative Medicine. Which statement, if
made by the nursing student, indicates a need for further teaching regarding CAM
categories?
✓ "Magnetic therapy and massage therapy
are a focus of CAM."
, 13) The nurse hears a client calling out for help, hurries down the hallway to the
client's room, and finds the client lying on the floor. The nurse performs an
assessment, assists the client back to bed, notifies the health care provider of the
incident, and completes an incident report. Which statement should the nurse
document on the incident report?
✓ The client was found lying on the floor.
14) A client is brought to the emergency department by emergency medical
services (EMS) after being hit by a car. The name of the client is unknown, and the
client has sustained a severe head injury and multiple fractures and is
unconscious. An emergency craniotomy is required. Regarding informed consent for
the surgical
procedure, which is the best action?
✓ Transport the victim to the operating room for surgery.
15) The nurse has just assisted a client back to bed after a fall. The nurse and
health care provider have assessed the client and have determined that the client is
not injured. After completing the incident report, the nurse should implement which
action next?
✓ Reassess the client.
16) The nurse arrives at work and is told to report (float) to the intensive care unit
(ICU) for the day because the ICU is understaffed and needs additional nurses to care
for the clients. The nurse has never worked in the ICU. The nurse should take
which best action?
✓ Clarify with the team leader to make a safe ICU client assignment.
17) The nurse who works on the night shift enters the medication room and finds a
co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to
insert a needle, attached to a syringe containing a clear liquid, into the antecubital
area. Which is the most appropriate action by the nurse?
✓ Call the nursing supervisor.
18) A hospitalized client tells the nurse that an instructional
directive is being prepared and that the lawyer will be bringing the document to the
hospital today for witness signatures. The client asks the nurse for assistance in
obtaining a
witness to the will. Which is the most appropriate response to the client?
✓ "I will call the nursing supervisor to seek assistance regarding
your request."
18) The nurse has made an error in a narrative documentation of an
assessment finding on a client and obtains the client's record to correct the
error. The nurse should take which actions to correct the error? Select all
that apply.
, ✓ Document the correct information and end with the nurse's signature
and title.
✓ Draw 1 line through the error, initialing and dating it.
19) Which identifies accurate nursing documentation notations? Select all
that apply.
✓ The client slept through the night.
✓ Abdominal wound dressing is dry and intact without drainage.
✓ The client's left lower medial leg wound is 3 cm in length without
redness, drainage, or edema.
20) A nursing instructor delivers a lecture to nursing students regarding the issue
of client's rights and asks a nursing student to identify a situation that represents an
example of invasion of client privacy. Which situation, if identified by the student,
indicates an understanding of a violation of this client right?
✓ Observing care provided to the client without the client's permission
21) Nursing staff members are sitting in the lounge taking their morning break. An
unlicensed assistive personnel (UAP) tells the group that she thinks that the unit
secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the
nursing staff that the secretary probably contracted the disease from her husband,
who is supposedly a drug addict. The registered nurse should inform the UAP that
making this accusation has violated which legal tort?
✓ Slander
22) An 87-year-old woman is brought to the emergency department for treatment
of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic
areas on the client's chest and legs and asks the client how the bruises were
sustained. The client, although reluctant, tells the nurse in confidence that her son
frequently hits her if supper is not prepared on time when he arrives home from work.
Which is the most appropriate nursing response?
✓ "As a nurse, I am legally bound to report abuse. I will stay with
you while you give the report and help find a safe place for you to stay."
23) The nurse calls the heath care provider (HCP) regarding a new medication
prescription because the dosage prescribed is higher than the recommended dosage.
The nurse is unable to locate the HCP, and the medication is due to be administered.
Which action should the nurse take?
✓ Contact the nursing supervisor.
REVIEW FOR NCLEX
The nurse is providing discharge instructions to a Chinese American client regarding
prescribed dietary modifications. During the teaching session, the client
continuously turns away from the nurse. The nurse should implement
which best action?
✓ Answers-Continue with the instructions, verifying
client understanding.
2) A critically ill Hispanic client tells the nurse through an interpreter that
she is Roman Catholic and firmly believes in the rituals and traditions
of the Catholic faith. Based on the client's statements, which actions by
the nurse demonstrate cultural sensitivity and spiritual support? Select
all that apply.(1,2,5)
✓ Answers-Ensures that a close relative stays with
the client
✓ Makes a referral for a Catholic priest to visit the client
✓ Offers to provide a means for praying the rosary if
the client wishes.
3) Which clients have a high risk of obesity and diabetes mellitus? Select
all that apply.(1,2,4,5)
• Latino American Man
• Native American man
• Hispanic American man
• African American woman
4) The nurse is preparing a plan of care for a client, and is asking the
client about religious preferences. The nurse considers the client's
religious preferences as being characteristic of a Jehovah's Witness if
which client statement is made?
✓ "I cannot have any food containing or
prepared with blood."
5) The ambulatory care nurse is discussing preoperative procedures with
a Japanese American client who is scheduled for surgery the following
week. During the discussion, the client continually smiles and nods the
head. How should the nurse interpret this nonverbal behavior?
✓ Answers-Reflecting a cultural value
6) When communicating with a client who speaks a different language,
which best practice should the nurse implement?
✓ Arrange for an interpreter to translate.
, 7) The nurse educator is providing in-service education to the nursing
staff regarding transcultural nursing care; a staff member asks the
nurse educator to provide an example of the concept of acculturation.
The nurse educator should make which most appropriate response?
✓ Answers-"A person who moves from China to the
United States (U.S.) and learns about and adapts ato the culture in
the U.S."
8) An Asin American client is experiencing a fever. The
nurse plans care so that the client can self-treat the disorder using which method?
✓ Foods considered to be yin
9) Which meal tray should the nurse deliver to a client
of Orthodox Judaism faith who follows a kosher diet?
✓ Sweet and sour chicken with rice and vegetables, mixed
fruit, juice.
10) Which is the best nursing intervention
regarding complementary and alternative medicine?
✓ Educating the client about therapies that he or she is using
or is interested in using
11) An antihypertensive medication has been prescribed for a client with hypertension.
The client tells the clinic nurse that he would like to take an herbal substance to help
lower his blood pressure. The nurse should take which action?
✓ Encourage the client to discuss the use of an herbal substance with
the health care provider (HCP).
12) The nurse educator asks a student to list the 5
main categories of complementary and alternative medicine (CAM), developed by the
National Center for Complementary and Alternative Medicine. Which statement, if
made by the nursing student, indicates a need for further teaching regarding CAM
categories?
✓ "Magnetic therapy and massage therapy
are a focus of CAM."
, 13) The nurse hears a client calling out for help, hurries down the hallway to the
client's room, and finds the client lying on the floor. The nurse performs an
assessment, assists the client back to bed, notifies the health care provider of the
incident, and completes an incident report. Which statement should the nurse
document on the incident report?
✓ The client was found lying on the floor.
14) A client is brought to the emergency department by emergency medical
services (EMS) after being hit by a car. The name of the client is unknown, and the
client has sustained a severe head injury and multiple fractures and is
unconscious. An emergency craniotomy is required. Regarding informed consent for
the surgical
procedure, which is the best action?
✓ Transport the victim to the operating room for surgery.
15) The nurse has just assisted a client back to bed after a fall. The nurse and
health care provider have assessed the client and have determined that the client is
not injured. After completing the incident report, the nurse should implement which
action next?
✓ Reassess the client.
16) The nurse arrives at work and is told to report (float) to the intensive care unit
(ICU) for the day because the ICU is understaffed and needs additional nurses to care
for the clients. The nurse has never worked in the ICU. The nurse should take
which best action?
✓ Clarify with the team leader to make a safe ICU client assignment.
17) The nurse who works on the night shift enters the medication room and finds a
co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to
insert a needle, attached to a syringe containing a clear liquid, into the antecubital
area. Which is the most appropriate action by the nurse?
✓ Call the nursing supervisor.
18) A hospitalized client tells the nurse that an instructional
directive is being prepared and that the lawyer will be bringing the document to the
hospital today for witness signatures. The client asks the nurse for assistance in
obtaining a
witness to the will. Which is the most appropriate response to the client?
✓ "I will call the nursing supervisor to seek assistance regarding
your request."
18) The nurse has made an error in a narrative documentation of an
assessment finding on a client and obtains the client's record to correct the
error. The nurse should take which actions to correct the error? Select all
that apply.
, ✓ Document the correct information and end with the nurse's signature
and title.
✓ Draw 1 line through the error, initialing and dating it.
19) Which identifies accurate nursing documentation notations? Select all
that apply.
✓ The client slept through the night.
✓ Abdominal wound dressing is dry and intact without drainage.
✓ The client's left lower medial leg wound is 3 cm in length without
redness, drainage, or edema.
20) A nursing instructor delivers a lecture to nursing students regarding the issue
of client's rights and asks a nursing student to identify a situation that represents an
example of invasion of client privacy. Which situation, if identified by the student,
indicates an understanding of a violation of this client right?
✓ Observing care provided to the client without the client's permission
21) Nursing staff members are sitting in the lounge taking their morning break. An
unlicensed assistive personnel (UAP) tells the group that she thinks that the unit
secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the
nursing staff that the secretary probably contracted the disease from her husband,
who is supposedly a drug addict. The registered nurse should inform the UAP that
making this accusation has violated which legal tort?
✓ Slander
22) An 87-year-old woman is brought to the emergency department for treatment
of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic
areas on the client's chest and legs and asks the client how the bruises were
sustained. The client, although reluctant, tells the nurse in confidence that her son
frequently hits her if supper is not prepared on time when he arrives home from work.
Which is the most appropriate nursing response?
✓ "As a nurse, I am legally bound to report abuse. I will stay with
you while you give the report and help find a safe place for you to stay."
23) The nurse calls the heath care provider (HCP) regarding a new medication
prescription because the dosage prescribed is higher than the recommended dosage.
The nurse is unable to locate the HCP, and the medication is due to be administered.
Which action should the nurse take?
✓ Contact the nursing supervisor.
