fundamentals review

4/5/2010

Prentice Hall Reviews & Rationales: Nursing Fundamentals, 2/e

Mary Ann Hogan RN, MSN, Mary Jean Ricci, Carl Ross

Chapter 03: NCLEX RN® Review Practice Test

You got 24 out of 30 questions correct

1. The nurse has explained a therapeutic diet to a client. To ensure that learning has occurred, the nurse should do which of the following?

You answered correctly: Listen to feedback from the client

Rationale: It is important for the nurse to listen to the feedback given by the client to ensure the message sent was the message received. Repetition is important in the teaching process but does not evaluate clients' understanding (option 1). Options 3 and 4 are unnecessary as part of evaluation.

Cognitive Level: Application

Client Need: Health Promotion and Maintenance

Integrated Process: Teaching and Learning

Content Area: Fundamentals

Strategy: The critical phrase is to ensure learning has occurred. In cognitive learning the nurse should listen to the client's verbalization of information to evaluate learning.

Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall, p. 465.

2. A nurse is trying to establish whether an unconscious client can communicate. Which of the following would be the best approach for the nurse to use?

You answered incorrectly: Observe for facial grimaces

The correct answer was: Ask questions that elicit a single act or response

Rationale: To evaluate an unconscious client's ability to communicate, it is best for the nurse to ask questions that will elicit a single act or response by the client. Option 1 is not appropriate for the client's condition. Options 3 and 4 may be noted during neurological assessment, but do not relate to communication.


Client Need: Psychosocial Integrity

Integrated Process: Communication and Documentation


Strategy: The critical words are best approach. Remember that even if a client is unconscious, hearing may be present. Keep statements simple. Questioning should be yes/no.


3. A client who is blind has been admitted to the cardiac unit. Which of the following actions by the nurse would be best to promote adjustment to the environment?

You answered correctly: Explain unit noises and physical surroundings

Rationale: A client who is blind does not have the benefit of nonverbal cues to facilitate communication. It is important for the nurse to respond vocally to the client's needs. Options 1 and 4 are approaches that a nurse should use with a client who is hearing impaired. Placing a sign on the client's door encroaches on confidentiality.


Client Need: Safe, Effective Care Environment: Safety and Infection Control



Strategy: The critical words are blind and promote adjustment. Remember to always announce your presence to visually impaired client, familiarize the client with environment, and keep the environment consistent.

Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall, pp. 948-949.

4. Regardless of the format used, at what times would documentation be required by the nurse for a hospitalized client who has heart failure? Select all that apply.

You answered incorrectly: Each time the nurse provides care; Whenever the client's condition changes; After returning to the unit following an endoscopic procedure

The correct answers were: Whenever the client's condition changes; After returning to the unit following an endoscopic procedure

Rationale: Documentation needs to be done whenever a client's condition changes or procedures are completed. It is not always necessary to document a physician visit or when a client leaves the hospital room. The format the facility uses will determine what nursing care needs to be documented.


Client Need: Safe, Effective Care Environment: Management of Care



Strategy: The core issue of the question is knowledge of the timeliness of documentation in a client's medical records. Recall that awareness of guidelines for legal documentation is key to basic nursing care, so review this material if this question was difficult.


5. Client information shared by the nurse with a consulting nutritionist should accomplish which of the following purposes?

You answered incorrectly: Provide an account of client's general health care

The correct answer was: Ensure safety and continuity of care for client

Rationale: Information that is necessary to provide continuity of care and ensure safety of the client should be reported. A consulting service may need to know more about the client than the reason for the referral. Options 1 and 4 do not represent purposes of information sharing.





Strategy: The critical words are client information shared and consulting nutritionist. Recall that nurses collaborate to share information to implement plan of care, ensure client safety and provide continuity of care.


6. When conducting a record review for research purposes, it is imperative that the nurse does which of the following to maintain professional standards?

You answered correctly: Remove all client identifiers

Rationale: It is important that all client medical records be handled confidentially. The name, social security number, address, and other identifying information cannot be used. Options 1 and 2 may not be appropriate, depending on the type of research conducted. Option 4 does not relate specifically to professional standards.





Strategy: Note that the critical words are record review. Recall that maintaining a client's confidentiality is a key nursing responsibility to aid in making the correct selection.


7. A nurse documenting client care using the problem-oriented format would do which of the following that is specific to this format?

You answered correctly: Organize the record according to client's specific needs or problems.

Rationale: Problem-oriented records are organized according to the client's specific needs or problems. Source-oriented records are organized according to departments involved in client care (option 1). Records are not organized according to nursing care plan (option 3). All records are organized chronically in each of their sections (option 4).





Strategy: The critical words are problem oriented format. Recall that in problem oriented charting, the medical record has a problem list in the front of the chart to guide care and documentation.


8. Which of the following would be the best method for the nurse to use in describing a client's emotional state when charting?

You answered correctly: Include objective data and subjective statements

Rationale: Documentation needs to be accurate and concise and should include both subjective and objective data. Documentation should not be judgmental or unclear (option 2). The client's emotional state is an important indicator of the response to health status or care received, and should be documented in the client's record (option 4). Option 3 is not a statement that identifies a method for describing emotional state.





Strategy: The critical words are best method and emotional state. Recall that to document any client problem, it is important to include both subjective and objective data.


9. The home care nurse has asked the client to demonstrate self-injection technique. In doing so, the nurse is primarily attempting to determine which of the following?

You answered correctly: Client's ability to perform the skill

Rationale: A return demonstration specifically identifies the client's ability to perform a skill. The client's skill level may provide incidental information related to options 1, 2, and 4, but they are not the primary reasons for asking the client to demonstrate a skill.





Strategy: The critical phrase is client to demonstrate. Recall that return demonstration is a valuable evaluation tool for the nurse involved in client education.


10. The nurse determines that which of the following would be the most appropriate time to use confrontation as a therapeutic technique in communication?

You answered correctly: When a good relationship exists and client's anxiety level is low

Rationale: Confrontation should not be used as a therapeutic communication technique unless trust has been established in the nurse-client relationship. Because confrontation can be uncomfortable for the client, it is important for the nurse and client to have a trusting relationship as a foundation. The other options do not reflect this need.

Cognitive level: Application




Strategy: The critical words are most appropriate time and confrontation. Remember that in order for any communication to be most effective, there should be a working therapeutic relationship. Reason that since confrontation could produce anxiety in the client, it is better to do so when the client's baseline anxiety level is low.


11. The nurse is working with a student nurse in a psychiatric rotation who will be interviewing a client. The nurse encourages the student to use which of the following as the best method to document the interaction?

You answered correctly: Process recording

Rationale: Process recordings are educational tools used to assist student learners to examine objectively their communication styles and effects on the client.





Strategy: Review the types of documentation. Remember a process recording is a verbatim documentation of an interaction.


12. Which of the following teaching strategies is most likely to be effective for a nurse to use when providing health instruction to an adolescent client?

You answered correctly: Client contracting

Rationale: Client contracting provides adolescents with the ability to be involved in their care. Adolescents should be involved in planning and decision-making regarding their own health issues. Lecture, viewing a video, and role-play would not provide opportunity for feedback.





Strategy: The critical words are teaching strategies and adolescent. Recall that client teaching must be adapted to the client's developmental level to be most effective. Recall also that a learning contract permits freedom to accomplish goals and fosters respect which teens may find appealing.


13. The nurse working in an agency that uses the focus method for charting would enter which of the following items in the data section of the focus note?

You answered correctly: "Lungs clear to auscultation bilaterally"

Rationale: The statement "Lungs clear to auscultation" would go under the Data section using the focus charting method. The Action section records the nursing intervention used to address a client need. The Response section records the client's reaction or response to care delivered. Client outcome statements are not a category used in focus charting.





Strategy: The critical terms are data section and focus charting. Awareness of the components of common methods of recording will assist the nurse in accurate documentation. Recall that focused charting utilizes the format of data, action and response. Since lungs sounds provide information about client status, they are data and would be charted as such.


14. The physician is giving the nurse a telephone order for a client. The most appropriate action by the nurse would be to do which of the following?

You answered correctly: Read back the order to the physician, copy it onto the physician order sheet, and document it as a telephone order.

Rationale: Repeating the order back to the physician verifies that the nurse has heard the order correctly. The other options do not represent acceptable nursing practice. Having another nurse hear the order involves a third person in the communication process and may not validate the information.





Strategy: The core issue of the question is the safe and appropriate way to document a telephone order. Remember client safety is the most important aspect of taking orders over phone and reading back the order ensures that the order that was recorded was the order given.


15. A quality improvement nurse has been assigned to complete a record review of a unit's nursing documentation. The primary goal of the nurse is to do which of the following?

You answered correctly: Determine that the nursing care received by clients meets established standards.

Rationale: The primary purpose of a record review by a quality improvement nurse is to ensure that nursing care received by clients meets acceptable nursing standards. Although the data may be reported to nursing administration or be used for research purposes, this is not the primary purpose of the record review. To ensure that medical treatment is consistent with the client's condition is beyond the scope of nursing practice.





Strategy: The critical terms are quality improvement and primary goal. Recall that quality activities are the way to improve systems and care to help you in making a selection.


16. A nurse is evaluating a client's ability to change the surgical dressing before discharge. During the demonstration, the nurse notices the client has not performed the procedure correctly. What would be the most appropriate action by the nurse?

You answered correctly: Praise client for aspects of procedure done accurately and correct client's mistakes

Rationale: Praising the client for steps performed correctly provides positive reinforcement. In addition, explaining the client's mistakes reinforces the correct way to perform the procedure. For the nurse to re-do the dressing decreases the client's confidence. Praising the client without correcting the mistakes gives feedback that the procedure was done correctly. Having the client repeat the procedure and stating it was done correctly without further guidance does not reinforce or assist learning.





Strategy: The critical phrase is client has not performed the procedure correctly. Recall that positive reinforcement fosters learning and that incorrect performance needs to be corrected in order for the proper learning to occur. Select the option that provides for both of these.


17. A facility has recently implemented a critical pathway for clients undergoing hip replacement surgery. Using the critical pathway, when would the nurse write a progress note?

You answered incorrectly: After every shift to verify client's progress

The correct answer was: When client does not meet goals as expected

Rationale: Progress notes generally are written when the client does not respond as expected and does not meet the client care goals. Most critical pathways use charting by exception when client goals are not met, and these instances are referred to as variances.





Strategy: The critical terms are critical pathways and progress note. To begin with, recall that a critical pathway streamlines documentation when a client is achieving daily goals. Then recall that when the client does not progress as expected, a progress note is required to describe how the client's situation has varied from the expected standard for progress.


18. Which of the following would the nurse select as an appropriate nursing diagnosis for clients attending a community health educational program on accident prevention for the school-aged child?

You answered correctly: Health-seeking behavior

Rationale: Health-seeking behavior is a diagnostic label appropriate for clients seeking health information through community health education programs. The other diagnostic labels do not apply.



Integrated Process: Nursing Process: Planning


Strategy: The core issue of the question is the ability to select an appropriate nursing diagnosis. Because the ability to use NANDA nursing diagnoses is an essential nursing skill, review this information now if this question was difficult.


19. The nurse should write which of the following learning objectives when developing a teaching plan for an assigned client?

You answered correctly: Prior to discharge the client will identify 4 signs of infection

Rationale: Learning objectives are client-oriented and describe a client behavior. Teaching the client about signs of infection is a nurse behavior rather than a client behavior. The nurse demonstrating wound care and describing self-injection techniques using visual aids is a teaching method, not a client learning objective. Learning objectives must be measurable and contain a stated time frame.

Cognitive Level: Analysis




Strategy: The critical phrase is learning objective. Recall the criteria for learning objectives and use the process of elimination to make a selection.


20. A client with diabetes mellitus is not following the recommended diet and is inconsistent about taking oral antidiabetic medication. When beginning to discuss this situation with the client, which of the following is most important for the nurse to do first?

You answered correctly: Find out what the client knows about diabetes mellitus.

Rationale: When presenting information to a client it is important that the nurse find out what the client already knows and build on the client's existing knowledge. It is not necessary to consult with a physician or to have family members present. It is important when teaching to begin with basic concepts and progress to complex. However, clients may be already aware of the basic concepts. Nurses should always find out what the client knows first.





Strategy: The critical words are most important and first. This tells you that more than one option may be correct but that one of them has priority in terms of sequence. Recall basic education principles to aid in making the correct selection.


21. The nurse would ask a client to perform the self injection technique following the nurse's demonstration during what phase of the nursing process?

You answered incorrectly: Implementation

The correct answer was: Evaluation

Rationale: When teaching a skill to a client the means of evaluation is observing the client perform the skill to determine if the teaching/learning goal has been reached. This action represents the evaluation phase of the nursing process.





Strategy: The critical phrases are ask a client to perform and following nurse's demonstration. Recall that return demonstration is the method used to evaluate a psychomotor skill.

Reference Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 320.

22. A nurse planning learning activities for a client who needs to learn to self-inject insulin would choose what activity to involve the client and validate the client's ability to perform a skill?

You answered correctly: Return demonstrating

Rationale: Return demonstrating is an activity that actively involves the client and increases learner retention. The other options involve visual (options 1 and 2) and auditory (option 3) learning, but do not engage the client as fully as when the client participates actively.





Strategy: Critical words are learning activities and actively involve the client. Recall that psychomotor skills such as insulin self-injection are demonstrated by the nurse and followed by client return demonstration.

Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 449.

23. A nurse who is preparing a teaching plan for a diabetic client assesses the client's health beliefs, cultural values, and motivation for which specific purpose?

You answered correctly: Increase the likelihood of the client successfully mastering the material and learning skills.

Rationale: The client is more likely to accept a plan consistent with the client's value system. If not, the plan may be more difficult for a client to accept, and the nurse may need to modify it later based on the assessment data. Although the nurse wants to demonstrate caring (option 1), the assessment is not done at this time to evaluate learning. Clients are complex and learning about their culture, values and motivation does not guarantee that the nurse will understand how the client might respond to the plan of care (option 2). The assessment is broader than just determining which behaviors by the client need to change to increase the state of health.





Strategy: Note that the question addresses the broad range of client beliefs, cultural values, and motivation. Reason that the correct option must also represent a broad answer.


24. The nurse concludes that a client who verbalizes an understanding of the anger she felt after being diagnosed with cancer demonstrates which of the following?

You answered correctly: Learning in the affective domain

Rationale: Learning in the affective domain involves emotions, feelings, and attitudes. Learning in the cognitive domain (option 2) involves processing information by listening or reading facts. Learning in the psychomotor domain (option 3) involves learning by doing. Option 4 is a prior condition needed for the most effective learning to take place.





Strategy: The critical phrase is an understanding of the anger. Consider that anger is an emotional response to associate it with the affective domain.


25. A client's nonverbal communication consistently indicates discomfort when a person stands too close. Which of the following approaches should the nurse use when performing a physical assessment on this client? Select all that apply.

You answered incorrectly: Maintain a distance of 3 feet when not actually performing an assessment technique; Explain the purpose of the assessment and what is involved; Defer the assessment until a time that the client will be comfortable

The correct answers were: Explain the purpose of the assessment and what is involved; Maintain a distance of 3 feet when not actually performing an assessment technique

Rationale: The client will be less anxious about intimate space being invaded if the client knows the reason why and how it relates to health care. Ignoring the client's discomfort sends the message that the client's feelings are not important. Acknowledging the client's discomfort may be beneficial but is not the best option. Most clients prefer 3 feet intimate space. Deferring the assessment is not appropriate nursing practice.



Integrated Process: Nursing Process: Implementation


Strategy: The critical term is best approach. To answer the question correctly, recall that people are generally uncomfortable when healthcare providers are in close proximity and that explanations tend to ease anxiety regarding unfamiliar situations.

Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing; concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 266-267.

26. A nurse providing teaching on weight reduction compliments the client on exercising daily. This action will promote the teaching plan by providing the client with which of the following?

You answered correctly: Positive reinforcement

Rationale: Providing positive reinforcement is likely to increase the client's continued use of positive health behaviors. Option 2 is vaguer than option 1. Options 3 and 4 do not promote the client's healthy behavior.





Strategy: The critical phrase is promote the teaching plan. Recall that use of various techniques for reinforcing positive behavior changes will increase the likelihood those changes will be maintained and that providing feedback helps one to learn.


27. When interpreting a client's message it is important for the nurse to assess which of the following?

You answered correctly: Whether nonverbal and verbal communication are congruent

Rationale: Nonverbal behavior should be consistent with verbal communication to ensure the message sent is the message received. An ability to read (option 1), family structure and cultural background (option 2), and health beliefs (option 3) are not components of the communication process.





Strategy: The critical phrase is interpreting a client's message. Recall that communication has both verbal and nonverbal components and that knowledge of communication strategies will enhance client communication.


28. The nurse has been called to "float" to another department to take the place of a nurse who is going home. Prior to floating, the nurse's first priority should be to:

You answered correctly: Document all client care and conditions.

Rationale: Documentation is the means to communicate clients healthcare needs to all members of the healthcare team and is the most important to ensure continuity of care. Reporting to another nurse (including list of activities still to be done) also needs to be done. Telling clients he/she is leaving is appropriate, but it is not the most important item to ensure continuity of care. Not all clients may require side rails.


Client Need: Safe Effective Care Environment; Management of Care



Strategy: The core issue of the question is the nursing action that takes highest priority. Keep in mind that clear communication, which includes documentation, is key to providing safe client care. Eliminate option 1 because the individual client plans of care may detail the interventions needed by the clients. Putting up all side rails could be a means of restraint (option 3). Documentation (option 2) takes priority over telling the client one is floating (option 4).

Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 344-345.

29. After charting in a client's record, the nurse has discovered the charting was done in the wrong client's chart. How should the nurse correct this problem?

You answered correctly: Draw a line through the information and write "error" and initial it.

Rationale: The proper way to correct an error is to draw a line through the information and write the word "error" and initial the above it. All other ways listed are incorrect because they violate guidelines for legally defensible charting.





Strategy: The critical phrases are wrong client's chart and correct this error. Recall that after making an error in the client record, do not erase, blot out, or use correction fluid.


30. A nurse concludes it is acceptable to use abbreviations in a chart when which of the following conditions exist?

You answered correctly: Abbreviations are consistent with the facility's policies

Rationale: Abbreviations used in documentation need to be consistent with facility policies for documentation. The client's record is a permanent document that must be consistent with professional and legal standards, which include agency/facility policy.





Strategy: The critical words are acceptable and abbreviations. Apply guidelines for legal documentation and institutional policies and use the process of elimination to make a selection.

Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 342-343.

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