Fundamentals Of Nursing NCLEX Quiz 21

1. After assessing the client. the nurse formulates the following diagnoses. Place them in order of priority. with the most important (classified as high) listed first.A. ConstipationB. Anticipated grievingC. Ineffective airway clearanceD. Ineffective tissue perfusion.

ABCD

BCDA

CDAB

ADBC

The nurse prioritizes the diagnoses based on the urgency and potential harm to the client. Ineffective airway clearance (C) is the highest priority because it poses an immediate threat to the client's breathing and oxygenation. Ineffective tissue perfusion (D) is the next priority as it can lead to tissue damage and impaired healing. Constipation (A) is of lower priority as it does not pose an immediate threat to the client's health. Anticipated grieving (B) is the lowest priority as it is a psychosocial concern that can be addressed after addressing the client's physiological needs.

Explanation

The nurse prioritizes the diagnoses based on the urgency and potential harm to the client. Ineffective airway clearance (C) is the highest priority because it poses an immediate threat to the client's breathing and oxygenation. Ineffective tissue perfusion (D) is the next priority as it can lead to tissue damage and impaired healing. Constipation (A) is of lower priority as it does not pose an immediate threat to the client's health. Anticipated grieving (B) is the lowest priority as it is a psychosocial concern that can be addressed after addressing the client's physiological needs.

2. The best explanation of what Title VI of the Civil Rights Act mandates is the freedom to:

Pick any physician and insurance company despite one’s income

Receive free medical benefits as needed within the county of residence

Have equal access to all health care regardless of race and religion

Have basic care with a sliding scale payment plan from all health care facilities

Title VI of the Civil Rights Act mandates that individuals have equal access to all healthcare services regardless of their race and religion. This means that healthcare facilities cannot discriminate against individuals based on their race or religion when providing healthcare services. This ensures that everyone has the same opportunities to receive necessary medical care, promoting fairness and equality in the healthcare system.

Explanation

Title VI of the Civil Rights Act mandates that individuals have equal access to all healthcare services regardless of their race and religion. This means that healthcare facilities cannot discriminate against individuals based on their race or religion when providing healthcare services. This ensures that everyone has the same opportunities to receive necessary medical care, promoting fairness and equality in the healthcare system.

3. The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients. which client would the RN need to develop a care plan first?

A client who is ambulatory.

A client. who has a fever. is diaphoretic and restless.

A client scheduled for OT at 1300.

A client who just had an appendectomy and has just received pain medication.

This client’s needs are a priority.

Explanation

This client’s needs are a priority.

4. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis. which of the following would indicate the need for further action and analysis?

A client’s family attending a diabetic teaching session.

Canceling physical therapy sessions on the weekend.

Normal VS and absence of wound infection in a post-op client.

A client demonstrating accurate medication administration following teaching.

Canceling physical therapy sessions on the weekend would indicate the need for further action and analysis because it deviates from the planned critical path of care. The cancellation of these sessions could potentially impact the client's rehabilitation progress and delay their recovery. Therefore, the nurse should investigate the reasons for the cancellation and determine if alternative arrangements need to be made to ensure continuity of care and optimal outcomes for the client.

Explanation

Canceling physical therapy sessions on the weekend would indicate the need for further action and analysis because it deviates from the planned critical path of care. The cancellation of these sessions could potentially impact the client's rehabilitation progress and delay their recovery. Therefore, the nurse should investigate the reasons for the cancellation and determine if alternative arrangements need to be made to ensure continuity of care and optimal outcomes for the client.

5. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to:

Implement the specialist’s recommendations.

Report the recommendations to the primary physician.

Clarify the suggestions with the client and family members.

Discuss and review advised strategies with CNS.

The primary nurse requested the consultation. it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations.Option A: Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations. but not immediate implementation.Option B: This would be appropriate after first talking with the CNS about recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician.Option C: The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.

Explanation

The primary nurse requested the consultation. it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations.Option A: Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations. but not immediate implementation.Option B: This would be appropriate after first talking with the CNS about recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician.Option C: The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.

6. Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to:

Include care that is culturally congruent with the staff from predetermined criteria

Focus only on the needs of the client. ignoring the nurse’s beliefs and practices

Blend the values of the nurse that are for the good of the client and minimize the client’s individual values and beliefs during care

Provide care while aware of one’s own bias. focusing on the client’s individual needs rather than the staff’s practices

Without understanding one’s own beliefs and values. a bias or preconceived belief by the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment values. beliefs. practices should be identified by the nurse and used as a guide to identify the choices by the nurse to meet specific needs/outcomes of that client. Therefore identification of values. beliefs. and practices allows for planning meaningful and beneficial care specific for this client.

Explanation

Without understanding one’s own beliefs and values. a bias or preconceived belief by the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment values. beliefs. practices should be identified by the nurse and used as a guide to identify the choices by the nurse to meet specific needs/outcomes of that client. Therefore identification of values. beliefs. and practices allows for planning meaningful and beneficial care specific for this client.

7. What should the nurse do when planning nursing care for a client with a different cultural background? The nurse should:

Allow the family to provide care during the hospital stay so no rituals or customs are broken

Identify how these cultural variables affect the health problem

Speak slowly and show pictures to make sure the client always understands

Explain how the client must adapt to hospital routines to be effectively cared for while in the hospital

Without assessment and identification of the cultural needs. the nurse cannot begin to understand how these might influence the health problem or health care management.

Explanation

Without assessment and identification of the cultural needs. the nurse cannot begin to understand how these might influence the health problem or health care management.

8. Transcultural nursing implies:

Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate

Working in another culture to practice nursing within their limitations

Combining all cultural beliefs into a practice that is a non-threatening approach to minimize cultural barriers for all clients’ equality of care

Ignoring all cultural differences to provide the best generalized care to all clients.

Transcultural care means that by understanding and learning about specific cultural practices the nurse can integrate these practices into the plan of care for a specific individual client who has the same beliefs or practices to meet the client’s needs in a holistic manner of care.

Explanation

Transcultural care means that by understanding and learning about specific cultural practices the nurse can integrate these practices into the plan of care for a specific individual client who has the same beliefs or practices to meet the client’s needs in a holistic manner of care.

9. Which factor is least significant during assessment when gathering information about cultural practices?

Language. timing

Touch. eye contact

Biocultural needs

Pain perception. management expectations

Cultural practices do not influence biocultural needs because they are inborn risks that are related to a biological need and not a learned cultural belief or practice.

Explanation

Cultural practices do not influence biocultural needs because they are inborn risks that are related to a biological need and not a learned cultural belief or practice.

10. Which of the following statements about the nursing process is most accurate?

The nursing process is a four-step procedure for identifying and resolving patient problems.

Beginning in Florence Nightingale’s days. nursing students learned and practiced the nursing process.

Use of the nursing process is optional for nurses. since there are many ways to accomplish the work of nursing.

The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.

Option A: The nursing process is a five-step process. Option B: The term nursing process was first used by Hall in 1955. Option C: Nursing process is not optional since standards demand the use of it.

Explanation

Option A: The nursing process is a five-step process. Option B: The term nursing process was first used by Hall in 1955. Option C: Nursing process is not optional since standards demand the use of it.