SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE.

SAUNDERS




1) The nurse is providing discharge instructions to a Chinese Americ
client regarding prescribed dietary modifications. During the teachi
session, the client continuously turns away from the nurse. The nurs
should implement which best action?



 Answers-Continue with the
instructions, verifying client
understanding.

1) A critically ill Hispanic client tells the nurse through an
interpreter that she is Roman Catholic and firmly believes
in the rituals and traditions of the Catholic faith. Based
on the client's statements, which actions by the nurse
demonstrate cultural sensitivity and spiritual
support? Select all that apply.(1,2,5)

 Answers-Ensures that a close
relative stays with
the client
 Makes a referral for a Catholic
priest to visit the client
 Offers to provide a means for
praying the rosary if the client
wishes.
2) Which clients have a high risk of obesity and diabetes
mellitus? Select all that apply.(1,2,4,5)
 Latino American Man
 Native American man
 Hispanic American man
 African American woman
3) The nurse is preparing a plan of care for a client, and is
asking the client about religious preferences. The nurse
considers the client's religious preferences as being
characteristic of a Jehovah's Witness if which client
statement is made?
 I cannot have any food containing
or Prepared with blood."

4) The ambulatory care nurse is discussing preoperative
procedures with a Japanese American client who is scheduled
for surgery the following week. During the discussion, the
client continually smiles and nods the head. How should the
nurse interpret this nonverbal behavior?

,  Answers-Reflecting a cultural value

5) When communicating with a client who speaks a different
language, which best practice should the nurse implement?

 Arrange for an interpreter to
translate.



6) The nurse educator is providing in-service education to the
nursing staff regarding transcultural nursing care; a staff
member asks the nurse educator to provide an example of the
concept of acculturation. The nurse educator should make
which most appropriate response?

 Answers-"A person who moves from
China to the United States (U.S.)
and learns about and adapts ato the
culture in the U.S."

7) An Asin American client is experiencing a fever. The nurse
plans care so that the client can self-treat the disorder
using which method?
 Foods considered to be yin

8) Which meal tray should the nurse deliver to a client of
Orthodox Judaism faith who follows a kosher diet?

 Sweet and sour chicken with rice
and vegetables, mixed fruit, juice.

9) Which is the best nursing intervention regarding
complementary and alternative medicine?

 Educating the client about
therapies that he or she is using
or is interested in using

10) An antihypertensive medication has been prescribed for
a client with hypertension. The client tells the clinic
nurse that he would like to take an herbal substance to help
lower his blood pressure. The nurse should take which
action?

,  Encourage the client to discuss the
use of an herbal substance with the
health care provider (HCP).



11) The nurse educator asks a student to list the 5 main
categories of complementary and alternative medicine (CAM),
developed by the National Center for Complementary and
Alternative Medicine. Which statement, if made by the
nursing student, indicates a need for further
teaching regarding CAM categories?

 "Magnetic therapy and massage
therapy are a focus of CAM."

12) The nurse hears a client calling out for help, hurries
down the hallway to the client's room, and finds the client
lying on the floor. The nurse performs an assessment,
assists the client back to bed, notifies the health care
provider of the incident, and completes an incident report.
Which statement should the nurse document on the incident
report?

 The client was found lying on the
floor.

13) A client is brought to the emergency department by
emergency medical services (EMS) after being hit by a car.
The name of the client is unknown, and the client has
sustained a severe head injury and multiple fractures and is
unconscious. An emergency craniotomy is required. Regarding
informed consent for the surgical procedure, which is
the best action?

 Transport the victim to the
operating room for surgery.

14) The nurse has just assisted a client back to bed after
a fall. The nurse and health care provider have assessed the
client and have determined that the client is not injured.
After completing the incident report, the nurse should
implement which action next?

,  Reassess the client.

15) The nurse arrives at work and is told to report (float)
to the intensive care unit (ICU) for the day because the ICU
is understaffed and needs additional nurses to care for the
clients. The nurse has never worked in the ICU. The nurse
should take which best action?

 Clarify with the team leader to
make a safe ICU client assignment.

16) The nurse who works on the night shift enters the
medication room and finds a co-worker with a tourniquet
wrapped around the upper arm. The co-worker is about to
insert a needle, attached to a syringe containing a clear
liquid, into the antecubital area. Which is the most
appropriate action by the nurse?

 Call the nursing supervisor.

17) A hospitalized client tells the nurse that an
instructional directive is being prepared and that the
lawyer will be bringing the document to the hospital today
for witness signatures. The client asks the nurse for
assistance in obtaining a witness to the will. Which is
the most appropriate response to the client?

 "I will call the nursing supervisor
to seek assistance regarding your
request."

19) The nurse has made an error in a narrative documentation
of an assessment finding on a client and obtains the
client's record to correct the error. The nurse should take
which actions to correct the error? Select all that apply.

 Document the correct information
and end with the nurse's signature
and title.

 Draw 1 line through the error,
initialing and dating it.