NGN/NCLEX Prep Questions/Rationales

NGN/NCLEX Prep Questions/Rationales

The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U

waves on a client's cardiac monitor screen. Fill in the correct missing information by choosing

from the lists of options in the drop-down menus.

The nurse should suspect

Your Answer: hypokalemia Correct Answer: hypokalemia

because of the

Your Answer: flattened T waves and occasional U waves Correct Answer: flattened T waves and

occasional U waves

Rationale: Cardiac changes in hypokalemia include impaired repolarization, resulting in a

flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse should

suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in

hypokalemia. The nurse should immediately assess the client's vital signs and cardiac status for

signs of hypokalemia. The nurse should also check the client's most recent serum potassium

level and then contact the primary health care provider to report the findings and obtain

prescriptions to treat the hypokalemic state.

The nurse is preparing a client for a chest x-ray and notes that the client is wearing a religious

medal on a chain around the neck. What should the nurse do with regard to this personal item?

Click to highlight the correct answer from the options provided.

The nurse should: (Select 1 option)

✓Ask the client if the chain and medal can be removed during the procedure.

Because: (Select 1 option)

✓The chain and medal may have cultural significance.

Rationale: Before certain diagnostic procedures, it is typical to have a client remove personal

objects that are worn on the body because of client safety and the possibility of compromising

test results. Therefore, the nurse should ask the client about the significance of such an item

and its removal because it may have cultural or spiritual significance. If so, the nurse should ask

the client if the item can be either removed temporarily or placed on another part of the body

during the procedure if appropriate.

While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I have

changed my mind. I don't want this surgery." Click to highlight the correct answer from the

options provided.

The nurse should: (Select 1 option)

Cancel the surgery.

Contact the surgeon.

✓Discuss the client's concerns.

Call the identified support person.

Because: (Select 1 option)

Client consent is required prior to any procedure.

✓Further questions or concerns should be determined and addressed.

Ethical considerations are important for a client undergoing surgery.

The nursing scope of practice places limitations on how the nurse can respond.

Rationale: If the client indicates that he or she does not want a prescribed therapy, treatment,

or procedure such as surgery, the nurse should further investigate the client's request. If the

client indicates that he or she has changed his or her mind about surgery, the nurse should

assess the client and explore with the client his or her concerns about not wanting the surgery.

The nurse would then withhold further surgical preparation and contact the surgeon to report

the client's request so that the surgeon can discuss the consequences of not having the surgery

with the client. Further assessment and follow-up related to the client's request need to be

done. It is the client's right to refuse treatment; however, further investigation is needed so the

interventions can be tailored to specific needs.

The nurse notes that there has been an increase in the number of intravenous (IV) site

infections that developed in the clients being cared for on the nursing unit. How should the

nurse proceed to implement a quality improvement program? For each action, click to specify

whether the action would be:

Indicated: an action that the nurse should take to resolve the problem

Non-essential: an action that the nurse could take without harming the client, but the action

would not be likely to address the problem

Contraindicated: an action that could harm the client and should not be taken

Collect identifying patient information

Contraindicated

Note the mental status of the client

Non-essential

Note primary and secondary diagnoses of clients affected

Indicated

Note the type of IV catheter used

Indicated

Note the type of IV site dressings being used

Indicated

Note the medication types being infused

Non-essential

Note frequency of assessments of IV sites

Indicated

Note the expected duration of the IV site

Non-essential

Note care procedures to the IV site

Indicated

Note frequency of changing IV sites

Indicated

Rationale: Quality improvement, also known as performance improvement, focuses on

processes or systems that significantly contribute to client safety and effective client care

outcomes; criteria are used to monitor outcomes of care and to determine the need for change

to improve the quality of care. If the nurse notes a particular problem, such as an increase in the

number of intravenous (IV) site infections, the nurse should collect data about the problem. This

should include information such as the primary and secondary diagnoses of the clients

developing the infection, the type of IV catheters being used, the site of the catheter, IV site

dressings being used, frequency of assessment and methods of care to the IV site, and length of

time that the IV catheter was inserted. Once these data are collected and analyzed, the nurse

should examine evidence-based practice protocols to identify the best practices for care to IV

sites to prevent infection. These practices can then be implemented and followed by evaluation

of results based on the evidence-based practice protocols used. Collecting identifying client

information is contraindicated because of confidentiality and is unnecessary in this quality

improvement effort. Noting the mental status of the clients can be done but is not likely to

address the problem. Noting the types of medications being infused can also be done, but will

not address the problem of IV site infection. Although it is helpful to know the expected

duration of the IV site, this information does not change infection control practices in managing

the IV site and is therefore considered a non-essential action.