Coordinated Care NCLEX PN

Extract:

Question 1 of 5

Which of the following nursing actions is most effective when evaluating a kinetic family drawing?

Correct Answer: D

Rationale: There are several guidelines for evaluating kinetic family drawings, including
Choice 4. Effective nursing actions include asking the client to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away.
Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child.

Question 2 of 5

Which of these would be the most appropriate way to document a client's refusal of medication?

A. Heparin refused during shift. Risks reviewed.' B. The client refused the heparin injection when I tried to administer it. She yelled at me saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift.' C. Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client and client verbalized understanding.' D. Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct and ct verbalized understanding.'

Correct Answer: C

Rationale: Documentation in healthcare should be objective, thorough, but direct. It should be articulate, with correct grammar and spelling.

Question 3 of 5

A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?

A. Risk for Self Harm B. Body Image Disturbance C. Ineffective Role Performance D. Powerlessness

Correct Answer: B

Rationale: Of the nursing diagnoses listed, the client's statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child. Nothing in the statement indicates that the client is at risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parent's role. Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility.

Question 4 of 5

Which is the correct order regarding the hierarchy of members of the nursing team from least authority to highest authority?A.staff nurse ,B.nurse manager,C.LPN ,D.charge nurse

A. A) C, D, A, B B. B) A, C, B, D C. C) C, A, D, B D. D) C, A, B, D

Correct Answer: C

Rationale: Nurse managers oversee charge nurses who oversee staff nurses who oversee LPNs.

Question 5 of 5

While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. The nurse should:

A. make the charge nurse on the unit aware of the situation so that he or she can take the necessary steps to maintain the confidentiality of the information being reported. B. disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway. C. return to his or her own unit and not disclose that confidential information has been overheard. D. ignore the situation.

Correct Answer: A

Rationale:
To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation so that the information can be communicated in an appropriate way in privacy.

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