Nclex Cris 2-50 Questions with 100% Correct Answers | Verified | Latest Update

Nclex Cris 2-50 Questions with 100%
Correct Answers | Verified | Latest
Update

Theinurseisupervisesitheitransferiofianielderlyiclientiwithileft-
sidediweaknessifromitheibeditoitheichair.iAfteriassistingitheiclientitoiaisi
ttingiposition,iwhichiofitheifollowingiactionsishoulditheinurseitakeiNEXT
?


1.iPlaceinonskidishoesionitheiclient'sifeet.
i


2.iInstructitheiclientithatisheiwillibeimovingitowardiherileftiside.
i


3.iAskitheiclientitoipivotioniherirightifoot.
i


4.iSupportitheileftilegiwithitheinurse'siknee.i-iCorrectiAnswer-
i

Strategy:iDetermineitheioutcomeiofieachianswer.


1)iCORRECT—
iinstructiclientitoiwearishoesiwhenitransferring,inonskidisolesidecreaseit

heichanceiofifalls


2)iificlientihasiweakeriside,itransferitowarditheistrongeriside;inurseishou
ldiassessiifiaitransferibeltiisirequired;iplaceichairiati45°iangleitoitheibed


3)iappropriateiaction;ifirstiputishoesioniclient;iinstructiclientitoiuseiarmr
estsionichairiforisupport

,4)iappropriateiactionitoiprovideistabilityitoiweakilegisoithaticlienticanist
andiduringitransfer


Ai16-year-
oldigirliisibroughtitoitheiemergencyiroomibyiheriparentsiforievaluationio
fianieatingidisorder.iWhenitheinurseiapproachesitheiclientitoidrawiaiblo
odisample,itheiclienticriesiout,i"Iihateihavingimyibloodidrawn.iGoiaway!
"iWhichiofitheifollowingiresponsesibyitheinurseiisiBEST?


1.i"What'sitheimatter?iAreiyouiafraidiofiwhatiweiareigoingitoifind?"
i


2.i"Whatiisiitiaboutihavingiyouribloodidrawnithatiupsetsiyou?"
i


3.i"Takeiaideepibreath.iItiwillibeioveribeforeiyouiknowiit."
i


i4.i"I'llibeibackiini15iminutesisoiweicanidiscussiyouriconcern."i-
iCorrectiAnswer-

Strategy:i"BEST"iindicatesidiscriminationiisirequireditoiansweritheiques
tion.


1)iyes/noiquestion;inurseiisimakingianiassumption


2)iCORRECT—iopen-
ended;irelatesitoiclient'siverbaliandinonverbalicommunicationiandiresp
ondsitoitheiclient'sifeelings


3)i"don'tiworry"iresponse;inontherapeutic

,4)idoinotileaveitheiclientialone


Theinurseicaresiforiclientsiinitheiprenataliclinic.iAiclienticomesitoitheiclin
iciforiaiprenatalivisitioniJunei6.iHerilastimenstrualiperiodiwasiDecemberi
10.iTheinurseiexpectsitheiclient'sifundaliheightitoimeasure


1.i24icm.
i


2.i26icm.
i


3.i28icm.
i


4.i30icm.i-iCorrectiAnswer-Strategy:iThinkiaboutieachianswer.
i




1)iincorrect,idetermineiEDCibasedioniNiäigele'sirule-
dateiLMPiDec.i10;iEDB-Sept.i17;iclientiisi26iweeksipregnant;ifromi24-
34iweeks,ifundaliheighticorrelatesiwelliwithiweeksiofigestation;i24icmiisi
approximatelyi24iweeks'igestation


2)iCORRECT—
iclientiisi26iweeksipregnant;ifundaliheightishouldicorrelateiwithiweeksio

fipregnancy


3)ifundusiisitooihigh


4)ifundusiisitooihigh

, Recentlyiseveralistaffimembersionitheiunitihaveicomplainediofibackistra
in.iTheinurseideterminesithatitheistaffiisinoticonsistentlyiusingicorrectib
odyimechanicsiwhenitransferringipatients.iWhichiofitheifollowingisugge
stionsishoulditheinurseimakeiFIRST?


1.i"Encourageiyouripatientsitoiassistiasimuchiasipossible."
i


2.i"Useiyouriarmsiandilegsiwhenimovingiaiclient."
i


3.i"Determineiifihelpiisirequireditoitransferiaipatient."
i


4.i"Positioniyourselficloseitoitheipatient."i-iCorrectiAnswer-
i

Strategy:iAssessibeforeiimplementing.


1)idecreasesitheinurse'siworkloadiandipromotesiclientistrengthiandiinde
pendence


2)iappropriateiaction;iuseitheilargerimusclesiofitheibodyiandinotitheibac
k;idon'titwistispine


3)iCORRECT—
ifirstistepiisitoiassess;idetermineitheiweightitoibeitransferrediandiifihelpi(

otheristaffimembers,imechanicalidevices)iisirequirediandiavailable


4)iminimizesitheiforceifeltibyitheinurse;ialwaysikeepiweightitoibeiliftedicl
oseitoitheibody