NCLEX

When do *advanced directives* go into effect? - when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* - *coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as signed; directives can always be changed later by person) SBAR Communication Framekwork Components - 1. *S* = Situation - what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background - *pertinent information, relevant history, vital signs* 3. *A* = Assessment - nurse's assessmen...

(Without understanding one's own beliefs and values, a bias or preconceived belief by the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment values, beliefs, practices should be identified by the nurse and used as a guide to identify the choices by the nurse to meet specific needs/outcomes of that client. Therefore identification of values, beliefs, and practi...

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation B. Alteration in comfort related to nausea and abdominal distent...

1. A nurse is asked about the goal of patient education. What is the nurse's best response? The goal of educating others is to help people a. Meet standards of the Nurse Practice Act. b. Achieve optimal levels of health. c. Become dependent on the health care team. d. Provide self-care only in the hospital. - ANS: B The goal of educating others about their health is to help individuals, families, or communities achieve optimal levels of health. Although all state Nurse Practice Acts ackn...

After receiving report at the start of the evening shift, which of the following clients should the nurse attend to first? (a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L. (b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10. (c) A 55-year-old woman with ovarian cancer waiting to be discharged. (d) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse oximetry of 96% on room air....

Which is the primary goal of community health nursing? A. To support and supplement the efforts of the medical profession in the promotion of health and prevention of B. To enhance the capacity of individuals, families and communities to cope with their health needs C. To increase the productivity of the people by providing them with services that will increase their level of health D. To contribute to national development through promotion of family welfare, focusing particularly on mot...

A nurse is providing care based on Maslow's hierarchy of basic human needs. For which nursing activities is this approach useful? a. Making accurate nursing diagnoses b. Establishing priorities of care c. Communicating concerns more concisely d. Integrating science into nursing care - b. Maslow's hierarchy of basic human needs is useful for establishing priorities of care. The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples of nursing inter...

A nurse is reviewing a patient's medication during shift change. Which of the following medication would be contraindicated if the patient were pregnant? Note: More than one answer may be correct. A: Coumadin B: Finasteride C: Celebrex D: Catapress E: Habitrol F: Clofazimine - (A) and (B) are both contraindicated with pregnancy. A nurse is reviewing a patient's PMH. The history indicates photosensitive reactions to medications. Which of the following drugs has not been associated wit...