NCLEX-RN
Communication and Documentation Questions
Extract:
Question 1 of 5
The nurse working on the mental health unit is in the orientation (introductory) phase of the therapeutic nurse-client relationship. Which intervention is representative of this phase of the relationship?
Correct Answer: A
Rationale: In the orientation (introductory phase) of the therapeutic nurse-client relationship, the client and nurse meet and determine the contract for time, such as how often to meet, the length of the meetings, and when termination is anticipated to occur. Utilizing services, identification with the nurse, and expression of feelings are appropriate for the working phase of the therapeutic nurse-client relationship.
Question 2 of 5
The student nurse is listening to a lecture on caring for clients with thrombophlebitis. Which statement by the student nurse indicates that the teaching has been effective?
Correct Answer: A
Rationale: The nurse plans to elevate the affected extremity because this facilitates venous return by using gravity to improve blood return to the heart, decreases venous pressure, and helps relieve edema and pain. Option 2 does not facilitate venous return and thus is not indicated for a client with thrombophlebitis. Options 3 and 4 are unsuitable activities for a client on bed rest.
Question 3 of 5
The nurse working on the mental health unit is in the orientation (introductory) phase of the therapeutic nurse-client relationship. Which intervention is representative of this phase of the relationship?
Correct Answer: A
Rationale: In the orientation (introductory phase) of the therapeutic nurse-client relationship, the client and nurse meet and determine the contract for time, such as how often to meet, the length of the meetings, and when termination is anticipated to occur. Utilizing services, identification with the nurse, and expression of feelings are appropriate for the working phase of the therapeutic nurse-client relationship.
Question 4 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 5 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.