NR 226 Exam 1 Practice questions and answers with rationales-1 PDF

Preview

Summary

NR 226 Exam 1 Practice NCLEX questions with answers and rationales, good study guide to practice...

Description

NR 226 Exam 1 Practice NCLEX questions with answers and rationales 1. A nurse cares for a client scheduled for surgery later in the day. The surgeon has back to back surgical cases and asks the nurse to explain the procedure and obtain informed consent. Which action does the nurse take? A. Contact the anesthesia provider to explain the procedure and then have the client sign the consent. B. Contact the physician’s nurse to discuss the procedure with the client and then have the client sign the informed consent. C. Explain the procedure to the client as best as possible and then have the client sign the informed consent. D. Wait for the provider to provide information to the client and then have the client sign the informed consent.

Explanation: With informed consent, the client should be informed of the risks and benefits of the procedure as well alternatives to the procedure and express understanding before signing the form. The health care provider performing the procedure is legally required to provide this information. Even after signing a consent, if the client has questions or doubts, the nurse should contact the health care provider to return and answer any questions the client may have. The nurse may review information provided by the provider but may not provide additional information. It is the nurse’s responsibility as client advocate to ensure the client understands the information which has been provided. The anesthesia provider can explain the anesthesia used for the surgery and obtain written informed consent for anesthesia. A nurse cannot provide information related to risks and benefits of a procedure in order to obtain consent for a surgical procedure. The provider performing the surgery must explain the procedure to the client and obtain written informed consent.

2. A nurse provides discharge instructions to a Chinese client. The client turns away from the nurse and does not make eye contact. Which actions are appropriate? A. B. C. D.

Ask the client to pay attention to instructions being given. Come back at a later time when the client is more interested. Continue providing the discharge instructions. Make every effort to make eye contact with the client.

Explanation: Asian clients, may, due to a difference in culture, show respect by not making eye contact or by avoiding direct face-to-face communication. It would be considered disrespectful to look the nurse in the eye. Continuing to provide the discharge instruction indicates an understanding of the client’s cultural differences during communication. Asking the client to pay attention does now show understanding of the client’s difference in cultural beliefs. Coming back at a later time makes an assumption based on one’s own cultural behaviors and does not indicate an understanding that the

client may respond differently based on cultural beliefs. Making every effort to make eye contact could offend the client by making an attempt to cause the client to do something deemed to be disrespectful.

3. The nurse cares for a client hospitalized due to postoperative complications. The nurse determines the client’s care plan needs revision. The nurse demonstrates which part of the nursing process? A. B. C. D.

Assessment Diagnosis Evaluation Planning

Explanation: The nursing process consists of assessment, nursing diagnosis, planning, implementation, and evaluation. These components are performed in consecutive order to achieve appropriate and optimal client outcomes. Understanding each component and applying it properly helps ensure the best plan of care given to the client. During the evaluation process, the nurse revises and updates the client’s plan of care according to the client’s status and any changes that occur. During the assessment phase of the nursing process, the nurse collects client data. In the diagnosis phase, the nurse determines potential or actual health problems for the client. In the planning phase, the nurse determines a strategy to resolve client’s problems.

4. A nurse completes a history intake on a client. The client informs the nurse the prescribed blood pressure medication is too expensive and has not been filled. Which healthcare team member does the nurse consult? A. B. C. D.

Chaplain Charge nurse Respiratory therapist Social worker

Explanation: Nurses work to collaborate on the care of clients in order to meet established goals and to prioritize care based on needs determined from assessment and diagnosis. Nurses work in collaboration with clients and their families, a variety of healthcare providers, pharmacists, social workers, physical therapists, medical assistants, respiratory therapists, and others to pool knowledge, reasoning, and critical thinking skills that promote or restore health. In this case a social worker can provide information related to needed resources for this client. The social worker can help the client to identify community resources that make it possible to pay for medications. There is no indication for a chaplain or respiratory therapist. There is no need to consult with the charge nurse regarding care of this client.

5. The nurse cares for a client with end-stage cancer who refuses treatment. The nurse understands that the client makes this choice based on which principle? A. B. C. D.

Autonomy Beneficence Nonmaleficence Justice

Explanation: Self-determination is the ability to make one’s own decisions. Autonomy in health care refers to the client’s ability to accept or refuse treatment. Beneficence is the desire to do good. Nonmaleficence is the idea of “do not harm.” Justice is the concept of being fair. Self-determination is not always based on beneficence, nonmaleficence, and justice.

6. An elderly client diagnosed with respiratory failure insists to the nurse to not be placed on a ventilator. Which action does the nurse take? A. B. C. D.

Consult with the client’s immediate family. Contact the client’s health care provider. Place a consult for hospice in the client’s chart. Place a do not resuscitate note on the client’s chart.

Explanation: A do not resuscitate order (DNR) or “no code” requires consultation with a health care provider prior to the form being completed and signed. The health care provider needs to verify client competency and understanding of the consequences associated with signing the form. Both the provider and the client then sign the form. This consultation should be documented in the client’s health record. The family may be a part of the consultation if the client wishes for them to be, but it is not required, or if the provider deems the client incompetent to make such a decision. These orders should be reviewed regularly with the client to ensure the client wishes to continue with the order. DNR protocols vary from state to state.

7. The nurse cares for a client in intensive care with a ventilator and intravenous infusions. The client is in a confused and combative state and is restrained at the wrists. Which interventions does the nurse perform? (Select all that apply). A. Allow family to remove restrains when they are present. B. Check distal pulse and capillary refill frequently. C. Check restraint placement once a shift.

D. Document why restraints are needed. E. Perform frequent skin checks.

Explanation: Restraints are used only when it is necessary for the safety and care of the client. A nurse must document reasons the restraints are in use and reassess throughout a shift and according to the institutions policies. Restraints must be assured to ensure they are not too tight or too loose and not causing skin breakdown in the areas they are applied. It is necessary to assess for skin breakdown, blisters, and rashes. Best practice would be to avoid the use of restraints if possible but if it is necessary the nurse is responsible for documenting their use and the client’s response. Restraints need to be checked more frequently than once a shift. A client’s status can change over time, making it necessary to document why restraints are needed for patient care and safety. While family may want to be involved, they should not be responsible for monitoring the client at bedside. If needed a hospital trained staff can provided one on one observation....