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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?

Correct Answer: B

Rationale: Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health care provider is to understand the client's perspective. 'Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death.'

Question 2 of 5

The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client's blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client's left arm. Which of these statements is most immediately accurate?

Correct Answer: D

Rationale: The UAP is responsible for carrying out the activity correctly once directions have been clearly communicated especially if given verbally and in writing.

Extract:

On the third day post partum day, a mother asks why her newborn's skin has begun to appear yellow.


Question 3 of 5

The nurse should plan to teach her that the change in skin tone is a result of:

Correct Answer: C

Rationale: Physiologic jaundice results from the breakdown of excess red blood cells in newborns.

Extract:


Question 4 of 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

Correct Answer: C

Rationale: The Admissions Office has the responsibility to verify the client's identity and keep all the records in the system consistent. Making changes puts the client at risk for misidentification.

Extract:

A manic client is being treated with lithium carbonate.


Question 5 of 5

The nurse would correctly suggest which of the following activities for this client.

Correct Answer: B

Rationale: Basketball provides physical activity to channel energy, suitable for a manic patient.

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