NCLEX-RN
Communication and Documentation Questions
Extract:
Question 1 of 5
While in the hospital, a client was diagnosed with coronary artery disease (CAD). Which question by the nurse is likely to elicit the most useful response for determining the client's degree of adjustment to the new diagnosis?
Correct Answer: B
Rationale: Exploring feelings assists the nurse with determining the individualized plan of care for the client who is adjusting to a new diagnosis. The correct option is the best question to ask the client because it is likely to elicit the most revealing information about the client's feelings about CAD and the requisite lifestyle changes that can help maintain health and wellness. The remaining choices are aspects of post-hospital care, but they are unlikely to uncover as much information about the client's adjustment to CAD because they are closed-ended questions.
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
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 4 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 5 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.