NURSING Med Surg 2 SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR-worthy to NOTE and USE

NURSING Med Surg 2 SAUNDERS COMPREHENSIVE

REVIEW FOR NCLEX

1)The nurse is providing discharge instructions to a Chinese American client regarding

prescribed dietary modifications. During the teaching session, the client continuously turns away from

the nurse. The nurse should implement which best action?

 Answers-Continue with the instructions, verifying client

understanding.

2) A critically ill Hispanic client tells the nurse through an interpreter that she is

Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith.

Based on the client's statements, which actions by the nurse demonstrate cultural

sensitivity and spiritual support? Select all that apply.(1,2,5)

 Answers-Ensures that a close relative stays with

the client

 Makes a referral for a Catholic priest to visit the client

 Offers to provide a means for praying the rosary if the client

wishes.

3) Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.

(1,2,4,5)

 Latino American Man

 Native American man

 Hispanic American man

 African American woman

4) The nurse is preparing a plan of care for a client, and is asking the client about

religious preferences. The nurse considers the client's religious preferences as being

characteristic of a Jehovah's Witness if which client statement is made?

 "I cannot have any food containing or

 prepared with blood."

5) The ambulatory care nurse is discussing preoperative procedures with a Japanese

American client who is scheduled for surgery the following week. During the

discussion, the client continually smiles and nods the head. How should the nurse

interpret this nonverbal behavior?

 Answers-Reflecting a cultural value

6) When communicating with a client who speaks a different language,

which best practice should the nurse implement?

 Arrange for an interpreter to translate.

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7) The nurse educator is providing in-service education to the nursing staff regarding

transcultural nursing care; a staff member asks the nurse educator to provide an

example of the concept of acculturation. The nurse educator should make

which most appropriate response?

 Answers-"A person who moves from China to the United States

(U.S.) and learns about and adapts ato the culture in the U.S."

8) An Asin American client is experiencing a fever. The nurse

plans care so that the client can self-treat the disorder using which method?

 Foods considered to be yin

9) Which meal tray should the nurse deliver to a client of

Orthodox Judaism faith who follows a kosher diet?

 Sweet and sour chicken with rice and vegetables, mixed fruit, juice.

10) Which is the best nursing intervention regarding complementary and

alternative medicine?

 Educating the client about therapies that he or she is using or is

interested in using

11) An antihypertensive medication has been prescribed for a client with

hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help

lower his blood pressure. The nurse should take which action?

 Encourage the client to discuss the use of an herbal substance with the health care

provider (HCP).

12) The nurse educator asks a student to list the 5 main

categories of complementary and alternative medicine (CAM), developed by the National Center for

Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates

a need for further teaching regarding CAM categories?

 "Magnetic therapy and massage therapy are a

focus of CAM."

13) The nurse hears a client calling out for help, hurries down the hallway to the client's room, and

finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed,

notifies the health care provider of the incident, and completes an incident report. Which statement

should the nurse document on the incident report?

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 The client was found lying on the floor.

14) A client is brought to the emergency department by emergency medical services (EMS) after

being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury

and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed

consent for the surgical procedure, which is the best action?

 Transport the victim to the operating room for surgery.

15) The nurse has just assisted a client back to bed after a fall. The nurse and health care provider

have assessed the client and have determined that the client is not injured. After completing the

incident report, the nurse should implement which action next?

 Reassess the client.

16) The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the

day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has

never worked in the ICU. The nurse should take which best action?

 Clarify with the team leader to make a safe ICU client assignment.

17) The nurse who works on the night shift enters the medication room and finds a co-worker

with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached

to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action

by the nurse?

 Call the nursing supervisor.

18) A hospitalized client tells the nurse that an instructional directive is being

prepared and that the lawyer will be bringing the document to the hospital today for witness

signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is

the most appropriate response to the client?

 "I will call the nursing supervisor to seek assistance regarding your

request."

18) The nurse has made an error in a narrative documentation of an assessment

finding on a client and obtains the client's record to correct the error. The nurse should take

which actions to correct the error? Select all that apply.

 Document the correct information and end with the nurse's signature and title.

 Draw 1 line through the error, initialing and dating it.

19) Which identifies accurate nursing documentation notations? Select all that apply.

 The client slept through the night.

 Abdominal wound dressing is dry and intact without drainage.

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 The client's left lower medial leg wound is 3 cm in length without redness,

drainage, or edema.

20) A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights

and asks a nursing student to identify a situation that represents an example of invasion of client

privacy. Which situation, if identified by the student, indicates an understanding of a violation of this

client right?

 Observing care provided to the client without the client's permission

21) Nursing staff members are sitting in the lounge taking their morning break. An unlicensed

assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired

immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably

contracted the disease from her husband, who is supposedly a drug addict. The registered nurse

should inform the UAP that making this accusation has violated which legal tort?

 Slander

22) An 87-year-old woman is brought to the emergency department for treatment of a fractured

arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and

legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse

in confidence that her son frequently hits her if supper is not prepared on time when he arrives home

from work. Which is the most appropriate nursing response?

 "As a nurse, I am legally bound to report abuse. I will stay with you while you

give the report and help find a safe place for you to stay."

23) The nurse calls the heath care provider (HCP) regarding a new medication prescription

because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate

the HCP, and the medication is due to be administered. Which action should the nurse take?

 Contact the nursing supervisor.

24) The nurse employed in a hospital is waiting to receive a report from the laboratory via the

facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead

receives a sexually oriented photograph. Which is the most appropriate initial nursing action?

 Call the nursing supervisor and report the incident.

25) The nurse is assigned to care for four clients. In planning client rounds, which client should the

nurse assess first?

26) The nurse employed in an emergency department is assigned to triage clients coming to the

emergency department for treatment on the evening shift. The nurse should assign priority to which

client?

27) A nursing graduate is attending an agency orientation regarding the nursing model of practice

implemented in the health care facility. The nurse is told that the nursing model is a team nursing

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