which of the following clients is most likely ready to be dismissed from an inpatient care setting to home

NCLEX-RN

Saunders NCLEX RN Practice Questions

1. Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?

A. A 65-year old male with urine output of 60cc in the past four hours
B. A 2-month old female with a temperature of 100.6 rectally
C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
D. A 4-year old male with an oxygen saturation of 96% on room air

Correct answer: A 4-year old male with an oxygen saturation of 96% on room air

Rationale: Clients must meet a certain amount of set criteria before they will be discharged from a healthcare facility. Although guidelines may vary between locations, most healthcare facilities expect clients to have adequate oxygenation, nutrition, and elimination; and be free from fever, vomiting, and significant pain

2. What is involved in obtaining informed consent?

A. An explanation of the reasons for the procedure
B. A signature on a form indicating the client agrees to the procedure
C. A statement affirming liability if complications arise during the procedure
D. Both A and C

Correct answer: An explanation of the reasons for the procedure

Rationale: Informed consent involves providing the client with an explanation of the reasons for the procedure, the potential risks, benefits, and available alternatives. It is essential for the healthcare provider to ensure that the client understands the information provided before agreeing to the procedure. While obtaining a signature on a consent form is part of the process, it is not the sole indicator of informed consent. Option C, which mentions liability statements, is incorrect as informed consent focuses on ensuring the client understands the procedure, not on affirming liability. Therefore, the correct answer is the explanation of the reasons for the procedure.

3. You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?

A. The infant had doubled their birth weight at twelve months.
B. The infant had tripled their birth weight at twelve months.
C. The mother reports that the infant is drinking 60 mLs per kilogram of its body weight.
D. The infant had grown ¼ inch since last month.

Correct answer: The infant had doubled their birth weight at twelve months.

Rationale: The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age. The mother’s reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown ¼ inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight. As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.

4. Which of the following may be a cultural barrier that impacts a healthcare provider's ability to provide care or education to the client?

A. A healthcare provider offers educational materials to a client that are written at an 8th-grade reading level
B. A Vietnamese woman wants to use steaming in addition to her prescription antibiotics
C. A healthcare provider uses pantomime to explain a procedure to a deaf client
D. A Native American client requests a healing ritual before considering surgery

Correct answer: A healthcare provider uses pantomime to explain a procedure to a deaf client

Rationale: Cultural barriers can impede communication, hindering a healthcare provider's ability to provide education or instructions about a client's care. In the context of cultural sensitivity, using pantomime to explain a procedure to a deaf client can be ineffective and inappropriate. This approach implies a lack of recognition of the importance of proper communication methods, such as sign language interpreters, which are crucial for effective communication with individuals who are deaf. Miscommunication is likely to occur if the client does not understand the gestures and actions of the healthcare provider. This scenario highlights the significance of understanding and respecting different cultural practices and communication needs to deliver optimal care and education. Choice A is incorrect because offering educational materials at an appropriate reading level demonstrates consideration for the client's literacy level, which can enhance understanding and compliance with medical instructions. Choice B is incorrect as incorporating a client's cultural practices, such as steaming, alongside prescribed treatments can be a part of culturally competent care. Choice D is incorrect as respecting a client's request for a healing ritual aligns with providing patient-centered care that acknowledges and integrates cultural beliefs and preferences.

5. Which of the following is an example of restorative care?

A. A nurse teaches a new mother how to breastfeed her infant
B. A nurse helps a client with developing a bladder-retraining program
C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
D. A nurse contacts the family of a client to tell them he will be out of surgery soon

Correct answer: A nurse helps a client with developing a bladder-retraining program

Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.