Nclex Exam Cram Practice Questions - Nurselytic

Correct Answer: C

Rationale: Client and family communication and education concerning restraints are essential to encourage cooperation. When the client and family understand the purpose and expected benefits of restraints, they are more likely to cooperate. This understanding can help prevent well-meaning family members from releasing restraints due to confusion or lack of information.
Therefore, choice C is correct.

Choices A, B, and D are incorrect because confusing both groups further, helping with coping and stress levels, and shifting responsibility to the client and family are not the primary goals of communication and education concerning restraints.

Correct Answer: A

Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.

Correct Answer: A

Rationale: The correct response is to show cultural awareness and acceptance by offering to assist in arranging for the medicine woman to be present. This demonstrates respect for the client's beliefs and preferences.
Choice B is inappropriate as it dismisses the client's request without considering its cultural significance.
Choice C is dismissive and does not acknowledge the client's values.
Choice D is disrespectful and judgmental, undermining the client's beliefs.
Therefore, the only appropriate and professional response is to support the client's request and offer assistance in accommodating it.

Correct Answer: D

Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger.
Choice A, 1 foot, is incorrect because it is too close to the fire and can expose the nurse to unnecessary risk.
Choice B, 2 feet, is also too close to the fire and may lead to potential harm. Similarly, choice C, 4 feet, is not the ideal distance as it is still within the range of potential danger. The correct answer is D, 6 feet, which is a safe distance for the nurse to extinguish the fire effectively without risking personal safety.

Correct Answer: A

Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client.
Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.