Final 100
1.A 26 year old man being admitted for an emergency appendectomy asks the nurse why she is asking about his medications and history of previous illnesses. In addition to explaining why it is relevant to the care of the client, the nurse knows this client responsibility has been outlined in which of the following?
Select one:
a. The Americans with Disabilities Act
b. HIPAA
c. Nursing Scope and Standards of Practice
d. The Patient’s Bill of Rights
2.A 43 year old patient with terminal ovarian cancer is admitted to the hospital with bowel obstruction. The patient is experiencing a great deal of pain and states, “please give me enough morphine to kill me.” The nurse’s best response would be:
Select one:
a. “I can see that you are in a lot of pain. Let me give you a back rub.”
b. “I am trying to understand what you are saying. Can you tell me how intense the pain is and what has helped before?”
c. “I can’t give you an overdose. but once you are discharged, you can do anything you want.”
d. “All right, I will give you a little extra medication.”
3.4A 58 year old man with head and neck cancer is admitted to the hospital and tell the nurse he does not want parenteral nutritional therapy as his cancer progresses. The nurse explains he can specify his wishes by creating an advance directive. The nurse knows that the requirement to provide clients with this type of information can be found in which of the following?
Select one:
a. The Patient Self-Determination Act
b. The Patient Protection and Affordable Care Act
c. Nursing Scope and Standards of Practice
d. The Patients’ Bill of Rights
4.A 65 year old woaman with metastatic breast cancer has been admitted to the hospital with neutropenic fever. She informs the nurse that she does not want CPR or artificial ventilation to be performed under any circumstances. The nurse explains that this information can be outlined in an advance directive. The nurse understands that which of the following addresses the client’s right to identify treatment desires in advance?
Select one:
a. The Patient Self-Determination Act
b. The Patient’s Bill of Rights
c. The Amernicans with Disibilities Act (ADA)
d. HIPAA (Health Insurance Portability and Accountability Act)
5.A child with a fracture of the left femur is being admitted to a pediatric unit. Which of the following actions is best for the nurse to take?
Select one:
a. Ask the nursing assistant to assess the peripheral pulsesof the child’s left leg while the nurse completes the admission forms.
b. Ask the nursing assistant to stay with the child and his parents while the nurse obtains phone orders from the physician.
c. Ask the nursing assistant to obtain equipment for the child’s care while the nurse talks with the child and his parents.
d. Ask the nursing assistant to obtain vital signs while the nurse obtains a history from the parents.
6.A client comes to the clinic because she thinks she is pregnant. She tells the nurse that she wants the pregnancy terminated because she and her husband do now want to have children, and then begins to cry. Which of the following statements by the nurse would be MOST appropriate?
Select one:
a. “Why are you so upset? You’re married and there’s no reason not to have a baby.”
b. “You seem upset. Let’s talk about how you’re feeling.”
c. “If you’re so upset, why don’t you have the baby put up for adoption?”
d. “Are you upset because you forgot to use birth control?”
7.A client has been hospitalized for 2 days for treatment of Hepatitis A. When the nurse enters the client’s room, he asks the nurse to leave him alone and stop bothering him. Which of the following responses by the nurse would be MOST appropriate?
Select one:
a. “I understand and will leave you alone for now.”
b. “Why are you angry with me?”
c. “You seem upset this morning.”
d. “Are you upset because you do not feel better?”
8.A client is admitted to the hospital with a diagnosis of Bipolar disorder. The man approaches the nurse and says, “Hi baby,” and opens his robe, under which he is naked. Which of the following comments by the nurse would be MOST appropriate?
Select one:
a. “This is inappropriate behavior. Please close your robe and return to your room.”
b. “I am offended by your behavior and I will report you.”
c. “Please dress in your clothes and then join us for lunch in the dining room.”
d. ” Oh my, you’re naked, do you need some assistance dressing today?”
9.A client is admitted to the hospital with an abdominal mass and is scheduled for an exploratory laparotomy. She asks the nurse admitting her, “Do you think I have cancer?” Which of the following responses by the nurse if MOST appropriate?
Select one:
a. “Would you like me to call your doctor so that you can discuss your specific concerns?”
b. “Don’t worry about it now; I’m sure you have many healthy years ahead of you.”
c. “Your tests show a mass. It must be hard not knowing what is wrong.”
d. “It sounds like you are afraid that you are going to die from cancer, I would be too honey.”
10.A client is admitted tothe emergency room with a diagnosis of acute myocardial infarction (Heart attack). The client tells the nurse: ” I’m scared, I think I’m going to die.” Which of the following responses by the nurse should be most appropriate?
Select one:
a. “I know what you mean, I thought I was having a heart attack once.”
b. “I will call your doctor so you can discuss it with her.”
c. “Everythink is going to be fine. We will take good care of you.”
d. “It is normal to feel frightened. You will be taken care of, tell me how you’re feeling.”
11.A client is being admitted to the hospital for elective surgery. During the admission assessment, the nurse asks the client if he has an advance directive. The nurse knows that clients have the right to play an active role in their care and treatment and this is guaranteed by which of the following?
Select one:
a. HIPAA
b. The Americans with Disabilities Act
c. The Civil Right Act of 1960
d. The Patient Self Determination Act
12.A client is placed in Buck’s traction. The nurse assigned to her prepares to assist her with a bath. The woman says, “You’re too young to know how to do this. Get me somebody who knows what they’re doing.” Which of the following is the most appropriate response by the nurse?
Select one:
a. “I am young, but I graduated from nursing school.”
b. “Your concerns are unnecessary, I know what I am doing.”
c. “Can you be more specific about your concerns?”
d. “If I don’t bathe you now, you’ll have to wait until I’m finished with my other clients.”
13.[2:14 PM, 2/25/2021] The Only Brownsugar: A client states she is afraid to have her cast removed from her fractured arm. Which of the following would be the MOST appropriate response by the nurse?
Select one:
a. “I don’t blame you, I’d be afraid too.”
b. “My aunt just had a cast removed and she’s just fine.”
c. “I know it is unpleasant. Try not to be afraid. I will help you.”
d. “You seem very anxious. I will stay with you while the cast is being removed.”
14.A fully alert and competent 89 year old patient is in end-stage liver disease. The patient says, “I am ready to die,” and refuses to take food or fluids. The family urges the patient to allow the nurse to insert a feeding tube. What is the nurse’s moral authority?
Select one:
a. The nurse must considerthat the hospital can be sued if the patient’s request is honored.
b. The nurse should honor the patient’s decision.
c. The nurse should obtain an order for a feeding tube.
d. The nurse should encourage the patient to reconsider the decision.
15.A mother whose young daughter has died of leukemia is crying and is unable to talk about her feelings. Which is the best response by the nurse?
Select one:
a. “She put up a good fight but now is out of pain and in heaven.”
b. “It must be hard to deal with such a precious loss.”
c. “Everyone will remember her because she was so cute. She was one of our favorites.”
d. “As hard as this is, it is probably for the best because she was in a lot of pain.”
16.A nurse is working on the medical/surgical unit. The nurse knows that which of the following tasks should NOT be delegated to nursing assistive personnel?
Select one:
a. Setting up a meal tray for a 75 year old client with Alzheimer’s disease
b. Transferring a 70 year old client awaiting discharge from the bed to a wheelchair.
c. Assessing a newly postoperative client’s pain level.
d. Setting up a water basin for a 45 year old client who wishes to shave at the bedside.
17.A patient is extremely upset and mentions something about a work-related issue that the nurse cannot understand. Whichof the following is the nurse’s best response?
Select one:
a. “Your job must be very important to you.”
b. “Calm down so I can understand what you are saying.”
c. “I’m not quite sure I heard what you said about your work.”
d. “It’s natural to worry about your job.”
`18.A patient is to have arthroscopic surgery of the knee to repair a torn tendon. The patient says, “I don’t know if I’ll make it through this surgery.” Which response by the nurse will encourage further communication by the patient?”
Select one:
a. “You are not going to die.”
b. “The type of surgery you are having is minor.”
c. “Everything will be all right.”
d. “Surgery often can be frightening.”
19.A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices a staff member who is not involved in the client’s care reading his medical record. The nurse knows she should FIRST do which of the following?
Select one:
a. Inform the staff member that without legitimate need for the information, staff should not be reading the medical record.
b. Nothing. The staff member has a hospital ID badge and is authorized to read the medical record.
c. Tell the client his medical records have been read by an unauthorized individual.
d. Page the physician and ask if it’s acceptable for the staff member to access the medical records.’
20.A woman is admitted to the hospital with high risk pregnancy. A laparotomy is scheduled. Preoperatively, which of the following goals is MOST important for the nurse to include on the client plan of care?
Select one:
a. Emotional support
b. Respiratory therapy
c. Fluid replacement
d. Pain relief’
21.An elderly client is hospitalized with Alzheimer’s disease. His daughter tells the nurse that caring for him is too hard, but that she feels guilty placing him in a nursing home. Which of the following statements by the nurse would be MOST appropriate?
Select one:
a. “Don’t feel guilty. The only solution is to place your father in a nursing home.”
b. “Would you like me to help you find a nursing home that is not too expensive?”
c. “I think I would feel guilty too if I had to place my father in a nursing home.”
d. “It is hard to be caught between taking care of your needs and your father’s needs.”
22.Like first stop the person from reading, before deciding to go tell
A nurse is caring for a client who states, “I have to check with my wife and see if she thinks I am ready to go home.” The nurse replies, “How do you feel about going home today?” Which clarifying technique is the nurse using to enhance communication with the client?
Select one:
a. Restating
b. Pacing
c. Reflecting
d. Paraphrasing
23.A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply)
Select one or more:
a. “Your daily routines will be different when you get home.”
b. “You will do great! You just have to get used to it.”
c. “Tell me about your support system you’ll have after you leave the hospital.”
d. ” Why are you worried about going home?”
24.A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply)
Select one or more:
a. “Your daily routines will be different when you get home.”
b. “You will do great! You just have to get used to it.”
c. “Tell me about your support system you’ll have after you leave the hospital.”
d. ” Why are you worried about going home?”
25.Which of the following strategies should a nurse use to establish a helping relationship with a client?
Select one:
a. Allow communication to occur spontaneously throughout the nurse-client relationship
b. Make sure the communication is equally reciprocal between the nurse and the client.
c. Encourage the client to communicate his thoughts and feelings.
d. Give the nurse-client communication no time limits.
26.The nurse is admitting a client who is jaundiced due to pancreatic cancer. The nurse should give the HIGHEST priority to which of the following needs?
Select one:
a. Nutrition
b. Urinary Elimination
c. Skin Integrity
d. Self-Image
27.The nurse is caring for a client hospitalized for observation after a fall. The client states, “My friend fell last year, and no one thought anything was wrong. She died 2 days later!” Which of the following responses by the nurse is BEST?
Select one:
a. “Don’t up think I’m taking good care of you?”
b. “This happens to quite a few people.”
c. “We are monitoring you, so you’ll be okay.”
d. “You’re concerned that it might happen to you?”‘
28.The nurse is caring for a famous basketball player who may have sustained a career changing injury. When asked by co-workers about the status of the client, she responds that she is not able to discuss her client. Which of the following ethical principles BEST supports her statement?
Select one:
a. Accountability
b. Justice
c. Beneficence
d. Confidentiality
29.The nurse is caring for a terminal cancer client at home. The nurse knows that which of the following ethical principles BEST supports keeping the client and family care consistent with the nurse’s professional code of ethics?
Select one:
a. Virtues
b. Fidelity
c. Justice
d. Beneficence
30.The nurse is conversing with a young adult client regarding an ordered blood transfusion. It is clear to the nurse that the client does not understand the risks involved with the procedure. Which of the following statements BEST describes the nurse’s role regarding informed consent for this procedure?
Select one:
a. The nurse has someone else witness the signature on the consent.
b. The nurse tells the client not to worry because blood transfusions are very common.
c. The nurse informs the ordering physician that the client does not understand the risks and will need further explanation.
d. The nurse describes alternative treatments.
31.The nurse is preparing a client for surgery. When obtaining informed consent, the nurse should INITIALLY do which of the following?
Select one:
a. Assess whether the client’s understanding of the procedure is sufficient to give consent.
b. Witness the client’s signature.
c. Explain the risks, benefits, and alternatives of the procedure.
d. Tell the client that obtaining the signature is routine for all surgeries.
32.The nurse is preparing to perform an admission assessment on a 28 year old man being admitted for Crohn’s disease. The nurse knows that according to the Patient’s Bill of Rights, this client is responsible for which of the following?
Select one:
a. Providing accurate information about medication and past illness
b. Providing information about personal relationships
c. Providing proof of insurance
d. Consenting to treatment
33.The nurse is present during an informed consent discussion between the client and the physician regarding recommended surgery. The physician discusses the risks, benefits and alternatives of the procedure with the client. The nurse knows that the client’s decision whether or not to have the surgery is based on which of the following ethical principles?
Select one:
a. Nonmaleficence
b. Beneficence
c. Autonomy
d. Capacity
34To better answer NCLEX style questions, the student should consider the correct order of the nursing process and:
Select one:
a. Evaluate and then plan
b. Assess and then implement
c. Document and then implement
d. Implement and then assess.
35What is the first step a student should take in actively developing a personal foundation for nursing practice
Select one:
a. Identify a personal ethical foundation
b. Identify ethical issues in the clinical setting.
c. Examine personal values and beliefs.
d. Read articles about ethical decision-making.
36. A nurse is using an interpreter to communication with a client. Which of the following actions should the nurse use when communicating with a client and his family? (Select all that apply.)
Select one or more:
a. Send at text message to the client
b. Ask the family one question at a time.
c. Send an Instagram photo to help explain the situation.
d. Do not interrupt the family and interpreter at they talk.
e. Use lay terms if possible
37.Which of the following is an example of a critical ethical and legal patient oriented issue?
Select one:
a. Individualized meal times
b. Rationing of care
c. Access to home care
d. The size of patient rooms
38.Which of the following is the correct order for prioritizing needs according to Maslow’s Hierarchy of Needs?
Select one:
a. Creative activities, feelings of accomplishment, friends
b. Psychological, basic, self-fulfillment needs
c. Friends, security, safety
d. Physical, safety, psychological needs
39.Which organization is responsible for ensuring the quality and integrity of baccalaureate, graduate, and residency programs in nursing through the process of accreditation?
Select one:
a. ANA
b. Sigma Theta Tau
c. CCNE
d. NLN
40.Which statement describes the following proverb: What you do speaks so loudly, I cannot hear what you say.
Select one:
a. When people talk too loudly it is hard to understand what is being said.
b. Hearing ability is an important factor in communicating.
c. Listening to what people say requires attention to what is being said.
d. Nonverbal messages are often more meaningful than words.
41.A nurse is caring for a client who is a Jehovah’s Witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. 42.The client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses should the nurse make ?
Select one:
a. “I know your family would approve of your decision to have a blood transfusion.”
b. “Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”
c. ” I believe in this case you should really make an exception and accept the blood transfusion.”
d. “Why does your religion mandate that you cannot receive any blood transfusions?”
43. The nurse is caring for a terminal cancer client at home. The nurse knows that which of the following ethical principles BEST supports keeping the client and family care consistent with the nurse’s professional code of ethics?
Select one:
a. Virtues
b. Fidelity
c. Justice
d. Beneficence
44. The nurse is admitting a client who is jaundiced due to pancreatic cancer. The nurse should give the HIGHEST priority to which of the following needs?
Select one:
a. Nutrition
b. Urinary Elimination
c. Skin Integrity
d. Self-Image
45A mother whose young daughter has died of leukemia is crying and is unable to talk about her feelings. Which is the best response by the nurse?
Select one:
a. “She put up a good fight but now is out of pain and in heaven.”
b. “It must be hard to deal with such a precious loss.”
c. “Everyone will remember her because she was so cute. She was one of our favorites.”
d. “As hard as this is, it is probably for the best because she was in a lot of pain.”
46. A 58 year old Spanish-speaking woman is being discharged after having a central venous access device placed. Which of the following BEST describes the nurse’s role in advocating for her client?
Select one:
a. The nurse provides both written and verbal discharge instructions.
b. The nurse uses a translator when she provides the client with discharge instructions.
c. The nurse provides discharges instructions in a private room.
d. The nurse ensures the client has transportation home upon discharge.
47.A client is admitted to the hospital with a diagnosis of Bipolar disorder. The man approaches the nurse and says, “Hi baby,” and opens his robe, under which he is naked. Which of the following comments by the nurse would be MOST appropriate?
Select one:
a. “This is inappropriate behavior. Please close your robe and return to your room.”
b. “I am offended by your behavior and I will report you.”
c. “Please dress in your clothes and then join us for lunch in the dining room.”
d. ” Oh my, you’re naked, do you need some assistance dressing today?”
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