NGN NCLEX RN ACTUAL Exam V2
1. 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"
2. 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
3. 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.
4. 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.
,5. 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.
6. 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).
7. 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.
8. 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.
9. 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.
10. 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.
11. 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
12. 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"
13. Abrupt, high-pitched snapping
noise:Answer:
heart murmur
14. 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
1. 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"
2. 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
3. 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.
4. 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.
,5. 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.
6. 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).
7. 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.
8. 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.
9. 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.
10. 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.
11. 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
12. 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"
13. Abrupt, high-pitched snapping
noise:Answer:
heart murmur
14. 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
