Nclex Exam Cram Practice Questions - Nurselytic

Correct Answer: C

Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized.
Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable.

Choices A, B, and D lack specificity and quantifiability.
Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.

Correct Answer: A

Rationale: The legal right to confidentiality of client information is waived when a court system subpoenas information. This occurs when information is required for legal proceedings to occur, such as through summonses, court orders, or litigation information necessary for the court. Subpoenas are legal orders that compel the disclosure of information. The other choices do not inherently waive the legal right to confidentiality. A family member's request for health care information would typically require the client's consent or fall under specific legal exceptions. A living will dictates end-of-life care preferences but does not necessarily waive confidentiality. Lastly, the declaration of incompetence may impact decision-making capacity but does not automatically waive confidentiality.

Correct Answer: A

Rationale: When providing perineal care to a female client, the nurse should wear gloves and wash the perineal area from front to back. This technique helps prevent the introduction of E. coli and other bacteria into the urethra, reducing the risk of urinary tract infections. Washing from back to front can introduce bacteria from the anal area to the urethra, leading to infections. Performing the procedure without gloves or having the client perform all care does not adhere to infection control practices. Pouring water from a sterile bottle alone may not ensure proper cleansing and infection prevention.
Therefore, choices B, C, and D are incorrect as they do not follow proper perineal care guidelines.

Correct Answer: A

Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.

Correct Answer: D

Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger.
Choice A, 1 foot, is incorrect because it is too close to the fire and can expose the nurse to unnecessary risk.
Choice B, 2 feet, is also too close to the fire and may lead to potential harm. Similarly, choice C, 4 feet, is not the ideal distance as it is still within the range of potential danger. The correct answer is D, 6 feet, which is a safe distance for the nurse to extinguish the fire effectively without risking personal safety.