NGN/NCLEX Prep Questions/Rationales Test.

NGN/NCLEX Prep Questions/Rationales Test. 1. The nurse notes the presence of a The nurse should suspect P wave, QRS complex, flattened T Your Answer: hypokalemiaCorrect Answer: hypokalemia waves, and occasional U waves on because of the a client's cardiac monitor screen. Your Answer: flattened T waves and occasional U Fill in the correct missing informa- wavesCorrect Answer: flattened T waves and occasional U tion by choosing from the lists of options in the drop-down menus. waves Rationale:Cardiac changes in hypokalemia include im- paired repolarization, resulting in a flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client's vital signs and cardiac status for signs of hy- pokalemia. The nurse should also check the client's most recent serum potassium level and then contact the prima- ry health care provider to report the findings and obtain prescriptions to treat the hypokalemic state. 2. The nurse is preparing a client for The nurse should: (Select 1 option) a chest x-ray and notes that the Ask the client if the chain and medal can be removed client is wearing a religious medal during the procedure. on a chain around the neck. What Because: (Select 1 option) should the nurse do with regard The chain and medal may have cultural significance. to this personal item? Click to highlight the correct answer from Rationale:Before certain diagnostic procedures, it is typi- the options provided. cal to have a client remove personal objects that are worn on the body because of client safety and the possibility of compromising test results. Therefore, the nurse should ask the client about the significance of such an item and its removal because it may have cultural or spiritual sig- nificance. If so, the nurse should ask the client if the item 3. While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I have changed my mind. I don't want this surgery." Click to highlight the correct answer from the op- tions provided. can be either removed temporarily or placed on another part of the body during the procedure if appropriate. The nurse should: (Select 1 option) Cancel the surgery. Contact the surgeon. Discuss the client's concerns. Call the identified support person. Because: (Select 1 option) Client consent is required prior to any procedure. Further questions or concerns should be determined and addressed. Ethical considerations are important for a client undergo- ing surgery. The nursing scope of practice places limitations on how the nurse can respond. Rationale:If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse should further investigate the client's request. If the client indicates that he or she has changed his or her mind about surgery, the nurse should assess the client and explore with the client his or her concerns about not wanting the surgery. The nurse would then withhold further surgical preparation and contact the surgeon to report the client's request so that the surgeon can dis- cuss the consequences of not having the surgery with the client. Further assessment and follow-up related to the client's request need to be done. It is the client's right to refuse treatment; however, further investigation is needed so the interventions can be tailored to specific needs. 4. The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the clients be- ing cared for on the nursing unit. How should the nurse proceed to implement a quality improve- ment program?For each action, Collect identifying patient information Contraindicated Note the mental status of the client Non-essential Note primary and secondary diagnoses of clients attect- ed Indicated Note the type of IV catheter used click to specify whether the action Indicated would be: Indicated: an action that the nurse should take to resolve the problem Non-essential: an action that the Note the type of IV site dressings being used Indicated Note the medication types being infused Non-essential Note frequency of assessments of IV sites nurse could take without harming Indicated the client, but the action would not be likely to address the prob- lem Contraindicated: an action that could harm the client and should not be taken Note the expected duration of the IV site Non-essential Note care procedures to the IV site Indicated Note frequency of changing IV sites Indicated Rationale:Quality improvement, also known as perfor- mance improvement, focuses on processes or systems that significantly contribute to