NCLEX Prioritization QUESTIONS WITH EXPLAINED ANSWERS 100% CORRECT

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Question 1 See full question Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the charge nurse to change her assignment. She is frustrated because she has had ... to devote so much time and energy to helping a newly licensed nurse provide discharge teaching for clients with diabetes mellitus. The charge nurse should: Correct response:  offer to assist with the discharge teaching needs. Explanation: Staff members need to know the charge nurse is a supportive leader who respects their honesty and stands behind them. By offering to help with discharge teaching, the charge nurse is actively engaging with her staff at a time of need. Changing all the assignments on this extremely busy floor would be counterproductive. Insisting that the staff member follow through with her assignment disrespects her request and genuine need. Providing a float nurse could help, but there are no guarantees a float nurse is available. Remediation:  Discharge Question 2 See full question During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis Correct response:  Providing a solution of viscous lidocaine for use as a mouth rinse Explanation: To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain. Remediation:  Impaired Oral Membrane Question 3 See full question A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client’s issues and is able to respond appropriately to the client’s needs? You Selected:  "It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." Explanation: The severe emotional trauma the girl has experienced will likely make it difficult for her to be successful in an adoptive placement at the present time, whether that placement is with someone she knows (the nurse) or another adoptive family. Additionally, adoption by the nurse is inappropriate because it blurs the lines between her professional and personal life and is likely to confuse the client. It is clear that the client has many issues and that love alone is not likely to solve all her problems. Treatment at the residential facility will allow her to work through emotional issues in a more therapeutic environment. Though not currently ready for adoption, she may be ready for adoption in the future after sufficient treatment. Question 4 See full question A client is about to undergo cardiac catheterization for which he signed an informed consent. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? Correct response:  Withhold the medication and notify the physician immediately. Explanation: The nurse should withhold the medication and notify the physician that the client does not understand the procedure. The physician then has the obligation to explain the procedure better to the client and determine whether or not the client understands. If the client does not understand, he cannot give a true informed consent. If the medication is administered before the physician explains the procedure, the sedation may interfere with the client's ability to clearly understand the procedure. The nurse may not just medicate the client and document the finding; the physician must be notified. The procedure does not need to be cancelled, only postponed until the client receives more education and is able to give informed consent. Remediation:  Decisional Conflict Question 5 See full question Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? [Show More]

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