SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE QUESTION AND ASNWERS

SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE QUESTION AND ASNWERS A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child? 1.Private room 2.Semiprivate room 3.4-bed ward room 4.Contact isolation room Correct Answer: Private room The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made? 1."Actual or life-threatening concerns are the priority." 2."Completing care in a reasonable time frame is the priority." 3."Time constraints related to the client's needs are the priority." 4."Obtaining the needed supplies to care for the client is the priority." Correct Answer: "Actual or life-threatening concerns are the priority." The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1.Open doors to client rooms. 2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. 5.Relocate ambulatory clients from the hallways back into their rooms. Correct Answer: 2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? 1.A client who requires a bed bath 2.An older client requiring frequent ambulation 3.A client who requires hourly vital sign measurements 4.A client requiring abdominal wound irrigations and dressing changes every 3 hours Correct Answer: A client requiring abdominal wound irrigations and dressing changes every 3 hours A client with diabetes mellitus is admitted to the hospital for eye surgery. Which task can be delegated to the unlicensed assistive personnel (UAP)? 1.Orient the client to the hospital surroundings. 2.Instruct the client on how to apply the eye drops. 3.Listen to the client express his frustration or loss. 4.Review hand washing and hygiene practices with the client. Correct Answer: Orient the client to the hospital surroundings. The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1.Actual or life-threatening concerns 2.Completing care in a reasonable time frame 3.Time constraints related to the client's needs 4.Obtaining needed supplies to care for the client Correct Answer: Actual or life-threatening concerns The nurse has received the client assignment for the day. Which client should the nurse care for first? 1.The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question about nutrition 2.The client receiving external radiation who has complaints of dryness and itching skin at the treatment area 3.The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site 4.The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination Correct Answer: The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign 4 clients and has 1 RN, 1 licensed practical (vocational) nurse, and 2 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1.The client who requires a 24-hour urine collection 2.The client with an abdominal wound requiring frequent wound irrigations 3.The older client requiring assistance with a bed bath and frequent ambulation 4.The client on a mechanical ventilator requiring frequent assessment and suctioning Correct Answer: The client with an abdominal wound requiring frequent wound irrigations The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? 1.A client requiring a colostomy irrigation 2.A client receiving continuous tube feedings 3.A client who requires urine specimen collections 4.A client with difficulty swallowing food and fluids Correct Answer: A client who requires urine specimen collections A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? 1."Cushing's syndrome is caused by excessive amounts of cortisol." 2."Cushing's syndrome is caused by decreased amounts of aldosterone." 3."Cushing's syndrome is caused by excessive amounts of antidiuretic hormone." 4."Cushing's syndrome is caused by decreased amounts of parathyroid hormone." Correct Answer: "Cushing's syndrome is caused by excessive amounts of cortisol." The nurse has received her client assignment for the day. Which client should the nurse care for first? 1.A client requiring a preoperative intravenous antibiotic 2.A client with emphysema who has shortness of breath after just ambulating 3.A client with serous drainage on an incisional spinal wound post laminectomy 4.A client with postoperative pain reported at 7 out of 10, with 10 being the worst Correct Answer: A client with postoperative pain reported at 7 out of 10, with 10 being the worst The graduate nurse is interviewed by the manager of a unit and is told that the manager's leadership style is laissez-faire or one of letting the staff nurses make the decisions about the unit's operations. Which question by the graduate nurse indicates the best understanding of the laissez-faire leadership style? 1."As the manager, do you maintain control and make all decisions?" 2."As the manager, do you assume a passive, nondirective approach?" 3."As the manager, do you facilitate decision making within the group?" 4."As the manager, do you change style according to the needs of the group?" Correct Answer: "As the manager, do you assume a passive, nondirective approach?" A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used. Correct Answer: Check the client's blood glucose level. Give the client ½ cup (118 mL) of fruit juice to drink. Take the client's vital signs. Retest the blood glucose level. Give the client a small snack of carbohydrate and protein. Document the client's complaints, actions taken, and outcome. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?