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This NCLEX-RN Diagnostic Test is comprised of 13 items, which must be completed within 10 minutes. |
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A client is being taught about living wills. Which of the client wishes can be described in a living will? Select all that apply.
Rationale: Living wills are used to describe actions a client would like to take place if they are still live, but unable to speak. The living will can ask that treatments be withheld or given. The living will is not the place where a power of attorney is named for healthcare or monetary purposes. When a power of attorney is named, the power of attorney would make the healthcare decisions for the client.
Category: Safe and Effective Care Environment
Subcategory: Management of Care/Advance Directives
Rationale: Living wills are used to describe actions a client would like to take place if they are still live, but unable to speak. The living will can ask that treatments be withheld or given. The living will is not the place where a power of attorney is named for healthcare or monetary purposes. When a power of attorney is named, the power of attorney would make the healthcare decisions for the client.
Category: Safe and Effective Care Environment
Subcategory: Management of Care/Advance Directives
A nurse describes several types of advance directives to a client. What is the best description for a health care proxy?
Rationale: A health care proxy is a person who will make health care decisions if the client is unable to make decisions. A health care proxy does not have the right to make other decisions, such as financial transactions. A durable power of attorney would be needed to make those decisions.
Category: Safe and Effective Care Environment
Subcategory: Management of Care/Advance Directives
Rationale: A health care proxy is a person who will make health care decisions if the client is unable to make decisions. A health care proxy does not have the right to make other decisions, such as financial transactions. A durable power of attorney would be needed to make those decisions.
Category: Safe and Effective Care Environment
Subcategory: Management of Care/Advance Directives
A client just moved to Ohio from Texas, where he had an advance directive in place. Where will the advance directive be honored?
Rationale: Different laws exist for each state. It is necessary for an advance directive to be filled out in each state where the patient lives because laws for resuscitation may be different. The client also must ensure their paperwork is current.
Category: Safe and Effective Care Environment
Subcategory: Management of Care/Advance Directives
Rationale: Different laws exist for each state. It is necessary for an advance directive to be filled out in each state where the patient lives because laws for resuscitation may be different. The client also must ensure their paperwork is current.
Category: Safe and Effective Care Environment
Subcategory: Management of Care/Advance Directives
A client has an advance directive for healthcare and is admitted to the hospital. How will the hospital staff obtain the information from the advance directive?
Rationale: The nurse should obtain the most recent advance directive by having a family member bring the advance directive to the hospital, if the client has not brought the advance directive with them. The physician is not responsible to keep the client’s most recent advance directive. The hospital should not use an old version of an advance directive as the client’s wishes may have changed.
Category: Safe and Effective Care Environment
Subcategory: Management of Care/Advance Directives
Rationale: The nurse should obtain the most recent advance directive by having a family member bring the advance directive to the hospital, if the client has not brought the advance directive with them. The physician is not responsible to keep the client’s most recent advance directive. The hospital should not use an old version of an advance directive as the client’s wishes may have changed.
Category: Safe and Effective Care Environment
Subcategory: Management of Care/Advance Directives
Jay, RN is caring for a client who has been diagnosed with cancer. The client refuses treatment for the cancer. What is the best example of advocacy?
Rationale: The nurse should respect the client’s wishes and ensure they are aware of all of their options. Ultimately, it is the client’s right to choose whether they will receive treatment or not. Palliative care does not treat the cancer, but can make the client more comfortable. This would be a good option for clients who refuse treatment.
Category: Safe and Effective Care Environment
Subcategory: Advocacy
Rationale: The nurse should respect the client’s wishes and ensure they are aware of all of their options. Ultimately, it is the client’s right to choose whether they will receive treatment or not. Palliative care does not treat the cancer, but can make the client more comfortable. This would be a good option for clients who refuse treatment.
Category: Safe and Effective Care Environment
Subcategory: Advocacy
Mary feels conflicted because her client has refused all treatments that the care provider has ordered. She believes that the client could die without getting these treatments. How can Mary best demonstrate advocacy?
Rationale: The nurse should work with the client to determine what types of treatments they are willing to accept and what they feel is beneficial for them. Clients may have a different interpretation of their illness, based on their backgrounds, attitudes, values and beliefs. Some clients may not believe in taking medications, or they may not have the money to continue treatments. It is important to include the client in the care plan.
Category: Safe and Effective Care Environment
Subcategory: Advocacy
Rationale: The nurse should work with the client to determine what types of treatments they are willing to accept and what they feel is beneficial for them. Clients may have a different interpretation of their illness, based on their backgrounds, attitudes, values and beliefs. Some clients may not believe in taking medications, or they may not have the money to continue treatments. It is important to include the client in the care plan.
Category: Safe and Effective Care Environment
Subcategory: Advocacy
A nurse is assigned to a client who has traveled from Saudi Arabia to obtain care. The nurse speaks minimal Arabic. What is the best action by the nurse?
Rationale: The client may speak some English, but they may not be familiar with American procedures and terminology. While it is good for the nurse to try to speak to the client in their native language, they also may not understand everything that is happening. The nurse should never have family members interpret for the client, as a different message could be relayed. They also might not understand the procedures or terminology.
Category: Safe and Effective Care Environment
Subcategory: Advocacy
Rationale: The client may speak some English, but they may not be familiar with American procedures and terminology. While it is good for the nurse to try to speak to the client in their native language, they also may not understand everything that is happening. The nurse should never have family members interpret for the client, as a different message could be relayed. They also might not understand the procedures or terminology.
Category: Safe and Effective Care Environment
Subcategory: Advocacy
The charge nurse is making assignments for the day. Which client can be assigned to the LPN? Select all that apply.
Rationale: Keep in mind that the LPN cannot complete admission assessments. They can also not transfuse blood products or provide initial education. The LPN can follow up on education that has already been provided. In general, the least complex clients should be assigned to the LPN.
Category: Safe and Effective Care Environment
Subcategory: Assignment, Delegation and Supervision
Rationale: Keep in mind that the LPN cannot complete admission assessments. They can also not transfuse blood products or provide initial education. The LPN can follow up on education that has already been provided. In general, the least complex clients should be assigned to the LPN.
Category: Safe and Effective Care Environment
Subcategory: Assignment, Delegation and Supervision
The charge nurse has an LPN on shift and is making the client assignments. 2 patients will be assigned to the LPN. Which clients should be assigned?
Rationale: Of the clients listed, the 2 lest complicated are the client with asthma, and the client with nausea and vomiting. The LPN should be able to care for these 2 clients because they wouldn’t be likely to need advanced IV medications or assessment. The client with GI bleeding will probably need a blood transfusion, which can’t be administered by the LPN.
Category: Safe and Effective Care Environment
Subcategory: Assignment, Delegation and Supervision
Rationale: Of the clients listed, the 2 lest complicated are the client with asthma, and the client with nausea and vomiting. The LPN should be able to care for these 2 clients because they wouldn’t be likely to need advanced IV medications or assessment. The client with GI bleeding will probably need a blood transfusion, which can’t be administered by the LPN.
Category: Safe and Effective Care Environment
Subcategory: Assignment, Delegation and Supervision
The nurse looks at a client’s rhythm on a telemetry monitor. What rhythm does the nurse recognize?
Rationale: This rhythm does not have a clear p wave, so the nurse should know that the impulses aren’t being conducted correctly from the atria. In atrial fibrillation, the QRS complexes may appear irregular vs in atrial flutter where they appear regular and the p waves look like sawthoothes. Treatment of this can vary, depending on how long the client has it and the symptoms. Usually, if symptomatic, the client will be placed on medication to convert the rhythm or may be cardioverted.
Category: Physiological Adaptation
Subcategory: Alterations in Body Systems
Rationale: This rhythm does not have a clear p wave, so the nurse should know that the impulses aren’t being conducted correctly from the atria. In atrial fibrillation, the QRS complexes may appear irregular vs in atrial flutter where they appear regular and the p waves look like sawthoothes. Treatment of this can vary, depending on how long the client has it and the symptoms. Usually, if symptomatic, the client will be placed on medication to convert the rhythm or may be cardioverted.
Category: Physiological Adaptation
Subcategory: Alterations in Body Systems