NCLEX Examination Challenge Flashcards
Health promotion and maintenance
Which statement by a client about herbal supplements indicates a need for further teaching by the nurse?
A. “I only take my herbs as instructed on the label of the containers.”
B. “I’ll tell my doctor that I’m on these herbs after I see if they work.”
C. “I will report any new side effects that I get from taking these herbs.”
D. “I will continue taking the medicine that was prescribed by my doctor”
Answer
Health promotion and maintenance And 80-year-old adult with severe back pain from osteoarthritis tells the nurse that she wants to participate in complementary and alternative therapies. Which therapies will the nurse recommend for this client? Select all that apply. A. Back massage B. Imagery C. Glucosamine D. Meditation E. Yoga
Answer
Health promotion and maintenance
Which statement by an older adult regarding her diet indicates a need for further teaching by the nurse?
A. “I need to eat more calories to help me keep warm this winter”
B. “I plan to eat more dairy foods like milk and yogurt every day”
C. “I’m going to have dinner with my friends more often”
D. “I plan to eat more raw fruits and whole-grain foods every day”
Answer
Psychological Integrity A community health nurse conducts an assessment of an older adult's medications. Which medication taken by the client every day has the highest risk for adverse drug events? A. Digoxin (Lanoxin) 0.375 mg B. Acetaminophen (Tylenol) 650 mg C. Furosemide (Lasik) 180 mg D. Amlodipine (Norvasc) 5 mg
Answer
Safe and effective care environment
A homeless client enters the emergency department smelling strongly of alcohol and having offensive body odor. He is drowsy and disoriented and has a staggering gait. What is the nurses first priority in caring for this client?
A. Establish trust to enhance communication
B. Notify the social worker or case manager on call
C. Keep the client safe to prevent a fall or other injury
D. Ask a nursing assistant to bathe the client
Answer
What are the recommended patient interview questions about sexual identity and healthcare?
- Do you have sex with men, women, with both, or neither?
- Does anyone live with you in your household?
- Are you in a relationship with someone who does not live with you?
- If you have sexual partner, have you or your partner been evaluated by the possibility of transmitting infections to each other?
- If you have more than one sexual partner how are you protecting both of you from infections, such as hepatitis B or hepatitis C are HIV?
- Have you disclosed your sexual identity and sexual activity to your healthcare provider?
- If you have not, I have your permission to provide that information to members of the healthcare team who are involved in your care?
- Would you consider as your closest family members?
Health promotion and maintenance
An older woman is admitted to the unit after her emergency abdominal surgery on PCA morphine. She has early Alzheimer’s disease and is attempting to pull out her IV line. What is the first method the nurse will use to assess this client’s pain level?
A. Ask her family or caregiver what they think her pain level is
B. Ask the client what her pain level is
C. Observe her body movements and facial expression
D. Assume she has pain and give her a bolus of PCA morphine
Physiological integrity
And 88-year-old woman is admitted for cardiac rehabilitation after an insertion of two coronary artery stents. While ambulating with her walker, the client reports chest pain. What is the nurses first action?
A. Take your heart rate and blood pressure
B. Stop her activity and provide a rest period
C. Call her healthcare provider immediately
D. Perform a stat electrocardiogram
! Nursing safety priority
Critical rescue
Before any transfer, carefully observe for potential problems, orthostatic, or postural, hypertension is a common problem in rehabilitation settings and contributes to falls, which are common for any patient with impaired mobility. If the patient moves from a lying to a sitting or standing position to quickly, his or her blood pressure drops, as a result, he or she becomes dizzy or faint. This problem is worsened by antihypertensive drugs, especially in older adults. To prevent this situation, help the patient change position slowly, but frequent rest periods to allow the blood pressure to stabilize. If needed, measure blood pressure with the patient in the lying, sitting, and standing positions to examine the differences. Orthostatic hypotension is indicated by a drop of more than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure between positions. Notify the healthcare provider and the therapist about this change.
What are the best practices for patient safety and quality care?
Transfer techniques for stroke patients
Bed to wheelchair or chair
Be sure that the patient wears a transfer (gate) belt
Place the chair at an angle to the bed on the patients strong side
Lock the wheelchair brakes, or secure the chair position
While holding on to the transfer belt, ask the patient to stand and move his or her strong hand to the armrest
Remind the patient to keep his or her body weight forward and pivot
When the patient’s legs touch the chair edge, guide the patient into a sitting position in the chair
Keep the transfer belt in place for transfer back into bed
What are the best practices for patient safety and quality care?
Transfer techniques for stroke patients
Wheelchair or chair to bed
Place the chair with the patient’s strong side next to the bed
Lock the wheelchair brakes, or secure the chair position
Ask the patient to stand, and move his or her strong hand to the armrest
Remind the patient to keep his or her bodyweight forward, and pivot
When the patient’s legs touch the bed edge, guide the patient until sitting and then reclining
Physiological integrity
Which statement by a newly paraplegic client indicates a need for the nurse to provide further teaching about his bowel retraining?
A. “I need to eat lots of high-fiber foods like beans and raw fruits.”
B. “I will drink at least 2 quarts of water or other liquids every day.”
C. “I’ll take oral laxatives every morning so I can go every day.”
D. “I plan to exercise by lifting weights and propelling my wheelchair.”
Answer
