Effective Communication Strategies for Nursing Professionals, Exams of Nursing

Download Effective Communication Strategies for Nursing Professionals and more Exams Nursing in PDF only on Docsity!

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

1. The nurse knows that which statement by the mother indicates that the mother

understands safety precautions with her four month-old infant and her 4 year-old child?

Review Information : The correct answer is D: "I have the four year-old hold and help

feed the four month-old a bottle in the kitchen while I make supper." The infant seat is to

be placed on the rear seat. Small children and infants are not to be left unsupervised.

Infants are to be placed on their "back when they go back" to sleep or are lying in a crib. A

4 year-old could assist with the care of an infant with proper supervision. This enhances

bonding with the infant and the

developmental needs of the preschooler to "help" and not feel left out.

2. Upon completing the admission documents, the nurse learns that the 87 year-old client

does not have an advance directive. What action should the nurse take?

Review Information : The correct answer is B: Give information about advance directives

For each admission, nurses should request a copy of the current advance directive. If

there is none, the nurse must offer information about what an advance directive implies.

It is then the client’s choice to sign it. In option 1 just recording the information is not

sufficient. In option 3 the nurse should not assume that the client has been informed of

choices for emergency care. In option 4 this represents an inappropriate delegation

approach.

3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after

the immunization was given, the client complains of itchy and watery eyes, increased

anxiety, and difficulty breathing. The nurse expects that the first action in the sequence

of care for this client will be to

A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary A) "I strap the infant car seat on the front seat to face backwards." "I place my infant in the middle of the living room floor on a B) blanket to play with my 4 year old while I make supper in the kitchen." C) "My stuck^ sleeping up in the^ baby air whilelies^ so the^ cute four^ in^ theyear^ crib old^ with naps^ the on^ little the sofa."buttocks D) "I bottle^ have in^ the the^4 kitchen^ year-old while^ hold I^ andmake^ help supper."^ feed^ the^ four^ month-old^ a

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is D: Call the provider for clarification Relying

on anyone else''s interpretation is very risky. When in doubt, check it out with the person

who wrote the illegible order. Order entry systems help to minimize this problem.

7. An adult client is found to be unresponsive on morning rounds. After checking for

responsiveness and calling for help, the next action that should be taken by the nurse is

to:

Review Information : The correct answer is D: open the client''s airway According to the

ABCs of CPR the first step in rescuing an unresponsive victim after checking

responsiveness and calling for help is to open the victims airway. The airway must be

opened appropriately before the need for rescue breaths can be determined. The pulse is

assessed, after breathing is evaluated. The need for abdominal thrusts is determined by

inability to achieve chest rise when ventilation is attempted.

8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers

that 800 ml has been infused after 4 hours. What is the priority nursing action?

Review Information : The correct answer is D: Ausculate the lungs

All of the options would be part of the evaluation for the effects of the large amount of

Leave the order for the oncoming staff to follow-up Contact the charge nurse for an interpretation Ask the pharmacy for assistance in the interpretation Call the provider for clarification A) Ask the client if there are any breathing problems B) Have the client void as much as possible C) Check the vital signs D) Ausculate the lungs A) check the cartoid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is C: 72 year-old recovering from surgery after

a hip replacement 2 hours ago

Look for the client who is in the least stable condition. The client who returned from

surgery 2 hours ago is at risk for hemorrhage and should be seen first. The 16 year-old

should be seen next because it is still the first post-op day. The 75 year-old in skin

traction should be seen next. The client who can safely be seen last is the 20 year-old

who is 2 weeks post-injury.

10. A nurse observes a family member administer a rectal suppository by having the

client lie on the left side for the administration. The family member pushed the

suppository until the finger went up to the second knuckle. After 10 minutes the client

was told by the family member to turn to the right side and the client did this. What is

the appropriate comment for the nurse to make?

Review Information : The correct answer is B: A toddler with severe deep abrasions over

98% of the body .This child has the least chance of survival. Severe deep abrasions are to

be thought of as second and third degree burns. The child has great risk of shock and

infection combined.

5. When admitting a client to an acute care facility, an identification bracelet is sent up

with the admission form. In the event these do not match, the nurse’s best action is to

Review Information : The correct answer is C: notify the admissions office and wait to

apply the bracelet

The Admissions Office has the responsibility to verify the client’s identity and keep all the

change whichever item is incorrect to the correct information use the bracelet and admission form until a replacement is supplied notify the admissions office and wait to apply the bracelet make a corrected identification bracelet for the client Why don’t we now have the client turn back to the left side. That was done correctly. Did you have any problems with the insertion? Let’s check to see if the suppository is in far enough. Did you feel any stool in the intestinal tract? An infant with intermittent buldging anterior fontonel between crying episodes A toddler with severe deep abrasions over 98% of the body A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture A school-age child with singed eyebrows and hair on the arms 16 year-old who had an open reduction of a fractured wrist 10 hours ago 20 year-old in skeletal traction for 2 weeks since a motor cycle accident 72 year-old recovering from surgery after a hip replacement 2 hours ago 75 year-old who is in skin traction prior to planned hip pinning surgery.

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

records in the system consistent. Making the changes puts the client at risk for

misidentification. Using an incorrect identification bracelet is unsafe. Making a new bracelet

on the unit is not appropriate.

6. The nurse is having difficulty reading the health care provider's written order that was

written right before the shift change. What action should be taken?

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is B: clean the meatus, begin voiding, then catch

urine stream

A clean catch urine is difficult to obtain and requires clear directions. Instructing the client

to carefully clean the meatus, then void naturally with a steady stream prevents surface

bacteria from contaminating the urine specimen. As starting and stopping flow can be

difficult, once the client begins voiding it''s best to just slip the container into the stream.

Other responses are not correct technique.

13. The provider orders Lanoxin (digoxin) 0.125 mg po and furosomide 40 mg every day.

Which of these foods would the nurse reinforce for the client to eat at least daily?

Review Information : The correct answer is B: watermelon Watermelon is high in

potassium and will replace any potassium lost by the diuretic. The other foods are not high

in potassium.

14. A nurse is stuck in the hand by an exposed needle. What immediate action

should the nurse take?

A) spaghetti B) watermelon C) chicken D) tomatoes A) Void a little, clean the meatus, then collect specimen B) clean the meatus, begin voiding, then catch urine stream C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine A) Look up the policy on needle sticks B) Contact employee health services C) Immediately wash the hands with vigor D) Notify the supervisor and risk management

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

An elderly client who had a myocardial infarction a week ago - UAP Review

Information : The correct answer is A: An admission at the change of shifts with atrial

fibrillation and heart failure - PN

The care for a new admissions should be performed by an RN. Since the client was

admitted at the change of shifts, the stability of the client would not have been

established. The charge nurse should take this client. The PN could monitor the IV fluids

in option C. Tasks that do not require independent judgment should be delegated. The

nurse may delegate the care for a stable client to a UAP.

19. A mother brings her 3 month-old into the clinic, complaining that the child seems to

be spitting up all the time and has a lot of gas. The nurse expects to find which of the

following on the initial history and physical assessment?

Review Information : The correct answer is B: Restlessness and increased mucus

production

This infant could be experiencing gastroesophageal reflux, or could be allergic to the

formula. Restlessness, irritability and increased mucus production can develop if an

allergy is present. Soy based formula is often recommended.

20. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by

the parents require follow-up and are consistent with the diagnosis?

Review Information : The correct answer is C: Immediately wash the hands with vigor

The immediate action of vigorously washing will help remove possible contamination. Then

the sequence would then be options 4, 1, 2.

A) Increased temperature and lethargy B) Restlessness and increased mucus production C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness."

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is C: "Clothes are becoming tighter across her

abdomen."

One of the most common signs of neuroblastoma is increased abdominal girth. The

parents'' report that clothing is tight is significant, and should be followed by additional

assessments.

21. A 16 year-old enters the emergency department. The triage nurse identifies that this

teenager is legally married and signs the consent form for treatment. What would be the

appropriate action by the nurse?

Review Information : The correct answer is D: Walk up and whisper in the student’s ear

“Stop. Aspirate. Then inject.”

This action is a direct threat to the client if the medication enters into the blood stream

instead of the muscle. The purpose of aspiration with IM injections is to prevent the

injection of the drug directly into the blood stream. Option 4 protects the client and is the

most professional.

16. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and

breathing is independent. What should the nurse document to most accurately describe the

client's condition?

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is D: Proceed with the triage process in the

same manner as any adult client

Minors may become known as an "emancipated minor" through marriage, pregnancy,

high school graduation, independent living or service in the military. Therefore, this client,

who is married, has the legal capacity of an adult.

22. A newly admitted elderly client is severely dehydrated. When planning care for this

client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?

Review Information : The correct answer is B: Glascow Coma Scale 8, respirations regular

The Glascow Coma Scale provides a standard reference for assessing or monitoring level of

consciousness. Any score less than 13 indicates a neurological impairment. Using the term

comatose provides too much room for interpretation and is not very precise.

17. A client enters the emergency department unconscious via ambulance from the client’s

work place. What document should be given priority to guide the direction of care for this

client?

A) Comatose, breathing unlabored B) Glascow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required Ask the teenager to wait until a parent or legal guardian can be contacted Withhold treatment until telephone consent can be obtained from the partner Refer the teenager to a community pediatric hospital emergency department Proceed with the triage process in the same manner as any adult client

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is B: Strep throat went through all the children

at the day care last month.

Evidence supports a strong relationship between infection with Group A streptococci and

subsequent rheumatic fever (usually within 2 to 6 weeks). Therefore, the history of

playmates recovering from strep throat would indicate that the child diagnosed with

rheumatic fever most likely also had strep throat. Sometimes, such an infection has no

clinical symptoms.

24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a

reluctance to interact with the client. The next action by the nurse should be to

Discuss the feeling of reluctance with an objective peer or supervisor Limit contacts with the client to avoid reinforcement of the manipulative behavior

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

30. Which statement best describes time

management strategies applied to the role of

a nurse manager?

Review Information : The correct answer is A: Discuss the feeling of reluctance with an

objective peer or supervisor

The nurse who experiences stress in the therapeutic relationship can gain objectivity

through supervision. The nurse must attempt to discover attitudes and feelings in the self

that influence the nurse- client relationship.

25. A client is being treated for paranoid schizophrenia. When the client became loud and

boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The

client willingly complied. The nurse’s action

A) Schedule staff efficiently to cover the needs on the managed unit B) Assume a fair share of direct client care as a role model C) Set daily goals with a prioritization of the work D) Delegate meetings^ tasks^ to^ reduce^ work^ load^ associated^ with^ direct^ care^ and Confront the client about the negative effects of behaviors on other clients and staff Develop a behavior modification plan that will promote more functional behavior

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is D: Abdominal mass and weakness Clinical

manifestations of neuroblastoma include an irregular abdominal mass that crosses the

midline, weakness, pallor, anorexia, weight loss and irritability.

32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the

adolescent indicates the need for additional teaching?

Review Information : The correct answer is A: Pain related to ischemia

Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands,

reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the

sympathetic nervous system and increased preload, further increasing myocardial

demands.

27. The provisions of the law for the Americans with Disabilities Act require nurse managers

to

A) Maintain an environment free from associated hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider both mental and physical disabilities A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety related to pain A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is A: "I will only have to wear this for 6

months."

The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. It

is used to correct curvature of the spine.

33. The nurse manager has been using a decentralized block scheduling plan to staff the

nursing unit. However, staff have asked for many changes and exceptions to the

schedule over the past few months. The manager considers self- scheduling knowing that

this method will

Review Information : The correct answer is B: Provide reasonable accommodations for

disabled individuals

The law is designed to permit persons with disabilities access to job opportunities.

Employers must evaluate an applicant’s ability to perform the job and not discriminate on

the basis of a disability.

Employers also must make "reasonable accommodations."

28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as

prescribed. Which client statement s from the assessment data is likely to explain his

noncompliance?

Review Information : The correct answer is C: "I have diminished sexual function."

Inderal, beta-blocking agent used in hypertension, prohibits the release of epinephrine into

the cells; this may result in hypotension which results in decreased libido and impotence.

A) "I have problems with diarrhea." B) "I have difficulty falling asleep." C) "I have diminished sexual function." D) "I often feel jittery." A) Improve the quality of care B) Decrease staff turnover C) Minimize the amount of overtime payouts D) Improve team morale A) "I will only have to wear this for 6 months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower."

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is D: Improve team morale

Nurses are more satisfied when opportunites exist for autonomy and control. The nurse

manager becomes the facilitator of scheduling rather than the decision- maker of the

schedule when self-scheduling exists.

34. A client is admitted to the emergency room following an acute asthma attack. Which of

the following assessments would be expected by the nurse?

Review Information : The correct answer is A: Diffuse expiratory wheezing In asthma,

the airways are narrowed - creating difficulty getting air in and a wheezing sound.

35. The nurse manager hears a health care provider loudly criticize one of the staff

nurses within the hearing of others. The employee does not respond to the health care

provider's complaints. The nurse manager's next action should be to

Review Information : The correct answer is D: Request an immediate private meeting

with the health care provider and staff nurse

Assertive communication respects the needs of all parties to express themselves, but not

at the expense of others. The nurse manager needs first to protect clients and other staff

from this display and come to the assistance of the nurse employee.

36. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation.

The client has been on the unit for 2 days and now states “I demand to be released

now!” The appropriate action is for the nurse to

Walk up to the health care provider and quietly state: "Stop this unacceptable behavior." Allow the staff nurse to handle this situation without interference Notify the of the other administrative persons of a breech of professional conduct Request an immediate private meeting with the health care provider and staff nurse A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills

BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2022

NURSING 216 NCLEX PRACTISE EXAM QUESTIONS AND ANSWERS

Review Information : The correct answer is C: Let’s discuss your decision to leave and

then we can prepare you for discharge.

A) You cannot be released because you are still suicidal. B) You can be released only if you sign a no suicide contract. C) Let’s for discharge.^ discuss^ your^ decision^ to^ leave^ and^ then^ we^ can^ prepare^ you D) You health^ have care^ a^ rightprovider's^ to^ sign discharge^ out^ as^ soon order.^ as^ we^ get^ an^ order^ from^ the