NCLEX-RN
Communication and Documentation Questions
Extract:
Question 1 of 5
After the surgical repair of a fractured hip, a client has consistently refused to engage in ambulation as prescribed. Which statement by the nurse will best encourage the client's need to ambulate?
Correct Answer: A
Rationale: Early ambulation during the postoperative period is very important to a client's health and recovery, but many different factors may be contributing to the client's refusal to ambulate as prescribed. Asking an open-ended question that encourages a discussion about getting out of bed is the best option available to allow the nurse to facilitate the client's plan of care. Pain may be a concern for the client, but again, the nurse is making an unfounded assumption. Although it is true that the recovery might be prolonged by not ambulating and the client may be depressed, these statements make assumptions about the reason the client is refusing to comply with the plan of care.
Question 2 of 5
The nurse assesses the client's peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and the fluid is not infusing. Which condition should the nurse document?
Correct Answer: C
Rationale: The infusion stops when the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness, and swelling of the IV site are the result of IV fluid infusing into the subcutaneous tissue. An IV site is infiltrated when it becomes dislodged from the vein and is lying in subcutaneous tissue, so the nurse concludes that the IV is infiltrated. The nurse needs to remove the infiltrated catheter and insert a new IV. All the remaining options are likely to be accompanied by warmth at the site.
Question 3 of 5
A client diagnosed with angina pectoris appears to be very anxious and states, 'So, I had a heart attack, right?' Which response should the nurse make to the client?
Correct Answer: D
Rationale: Angina pectoris occurs as a result of an inadequate blood supply to the myocardium causing pain; managing the condition will help address the client's pain. The nurse will want to correct the client's misconception regarding a heart attack while addressing the client's concerns. Option 1 does not address the client's concerns. Option 2 is not correct because angina involves interrupted blood supply but does not result in cardiac tissue damage. Neither the nurse nor the primary health care provider can guarantee that a heart attack will not occur as option 3 seems to indicate.
Question 4 of 5
When responding to the call bell, the nurse finds the client lying on the floor beside the bed. After a thorough assessment and appropriate care, the nurse completes an incident report. How should the incident be described in the report?
Correct Answer: C
Rationale: The incident report should contain the client's name, age, and diagnosis. It should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only option that describes the facts as observed by the nurse. All the remaining options are interpretations of the situation and are not factual data as observed by the nurse.
Question 5 of 5
A teenaged client is discharged from the hospital after surgery with instructions to use a cane for the next 6 months. What question best demonstrates the nurse's ability to use therapeutic communication techniques to effectively assess the teenager's feelings about using a cane?
Correct Answer: A
Rationale: The nurse effectively uses therapeutic communication techniques when posing an open-ended question to elicit assessment data about how the teenager feels about using a cane. The remaining options are closed-ended questions. Option 3 makes assumptions about how the teenager feels, and options 2 and 4 focus on the physical aspects of using the cane.