NCLEX-RN
Communication and Documentation Questions
Extract:
Question 1 of 5
The nurse is preparing a client for electroconvulsive therapy (ECT). After the client signs the informed consent form for the procedure, a family member states, 'I don't think that this ECT will be helpful, especially since it makes people's memory worse.' What form of communication should the nurse implement to address the family member's concern?
Correct Answer: C
Rationale: Involving the family member in a dialog allows the nurse to understand their concerns and provide accurate information about ECT, addressing misconceptions about memory loss. Option 1 shifts focus away from the family member's concern, option 2 provides premature reassurance without exploring the concern, and option 4 makes an assumption about the cause of memory impairment without addressing the family member's specific worry.
Question 2 of 5
The nurse is preparing a client for electroconvulsive therapy (ECT). After the client signs the informed consent form for the procedure, a family member states, 'I don't think that this ECT will be helpful, especially since it makes people's memory worse.' What form of communication should the nurse implement to address the family member's concern?
Correct Answer: C
Rationale: Involving the family member in a dialog allows the nurse to understand their concerns and provide accurate information about ECT, addressing misconceptions about memory loss. Option 1 shifts focus away from the family member's concern, option 2 provides premature reassurance without exploring the concern, and option 4 makes an assumption about the cause of memory impairment without addressing the family member's specific worry.
Question 3 of 5
The nursing student is listening to a lecture on correcting errors in a written narrative on a medical record. Which statement by the nursing student indicates that the teaching has been effective?
Correct Answer: B
Rationale: If the nurse makes a narrative documentation error in the client's record, the agency's policy should be followed to correct the error. Agency policy usually includes drawing one line through the error, initialing and dating the line, and then providing the correct information. The nurse uses a late entry to document additional information that was not documented at the time that it occurred. The nurse avoids attempting to remove the error by any means because these actions raise the suspicion of wrongdoing.
Question 4 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 5 of 5
The registered nurse is orienting a new nurse on how to care for a client diagnosed with type 2 diabetes mellitus, who was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). When preparing for discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. Which response by the new nurse is best?
Correct Answer: A
Rationale: The nurse should provide time and listen to the client's concerns while attempting to clarify the client's feelings as in the correct option. Option 2 is not an appropriate nursing response because it is making suggestions regarding care options without appropriately identifying the client's true concerns. Options 3 and 4 provide inappropriate false hope and disregard the client's concerns.