Coordinated Care NCLEX PN

Extract:

Question 1 of 5

Which of these is true regarding advance directives?

Correct Answer: D

Rationale: If summoned, EMTs are legally obligated to provide emergency care to a client, regardless of advance directive status, unless the directive is signed by a doctor. If the client is brought to the hospital, physicians will evaluate the client and implement the advance directive, if necessary. Two physicians, not one, are needed to determine if a client is unable to make decisions for himself/herself. Advance directives do not expire and remain in effect until they are changed. Some states do not honor advance directives created in other states, so if a client moves, he/she should check with his/her new state policies on this topic.

Question 2 of 5

An LPN works on an adult medical/surgical unit and has been pulled to work on the burn unit, which cares for clients of all ages. What should he do?

A. He should take the assignment, but make it clear he will only care for adult clients. B. He should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting. C. He should refuse to take the assignment, as caring for infant and child population is not within his scope of practice. D. He should take the assignment, but ask to be paired with a more experienced LPN.

Correct Answer: B

Rationale: While the LPN may specialize in a certain type of nursing or feel more comfortable caring for a specific client population, he should be able to use his skill set to safely and independently care for other populations as well. However, the LPN should let the charge nurse know his background before beginning his shift so he can familiarize himself with new equipment, ask questions, and identify resources.

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

The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following would be least appropriate?

A. Begin client data collection prior to receiving the physician's order for the referral. B. Use documents to contribute information for the referral. C. Wait for the physician to order speech therapy and then assist with the appropriate documentation. D. Participate in the client referral process.

Correct Answer: C

Rationale: The nurse should participate in the client referral process, collect client data, and use appropriate documents to contribute information. It is not necessary to wait for the physician's order if the nurse recognizes the need for client referral.

Question 5 of 5

The nurse is caring for a non-English speaking client. The surgeon has asked the nurse to hurry up and prepare the client for their scheduled procedure, which is running late. Which of the following is least appropriate?

A. Explain to the client's family member that the procedure may be delayed further. B. Inform the surgeon that the procedure will be delayed further because getting a staff interpreter will take additional time. C. Allow the client's family member to serve as the interpreter. D. Ask if a phone-service interpreting service is available to expedite the client preparation.

Correct Answer: C

Rationale: The client's family member should not be relied on as an interpreter.

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