a client has experienced a cva with right hemiparesis and is ready for discharge from the hospital to a long term care facility for rehab to provide

NCLEX-PN

NCLEX PN Test Bank

1. A client has experienced a CVA with right hemiparesis and is ready for discharge from the hospital to a long-term care facility for rehab. To provide optimal continuity of care, the nurse should do all of the following except:

A. document the current functional status
B. have the physician fax a report to the receiving facility
C. copy appropriate parts of the medical record for transport to the receiving facility
D. phone a report to the facility

Correct answer: B

Rationale: To ensure optimal continuity of care for a client transitioning to a long-term care facility for rehab after a CVA, the nurse plays a crucial role in communication. Documenting the current functional status is essential for the receiving facility to plan appropriate care. Copying relevant parts of the medical record for transport provides important background information. Phoning a report directly to the facility is a direct and effective way to communicate the client's condition and care plan. However, having the physician fax a report to the receiving facility introduces an extra step that may delay essential information transfer and increase the risk of miscommunication. Therefore, it is not the optimal choice for ensuring seamless continuity of care.

2. What should be included in the assessment of a client with a cast?

A. capillary refill, warm toes, no discomfort.
B. posterior tibial pulses, warm toes.
C. moist skin essential, pain threshold.
D. discomfort of the metacarpals.

Correct answer: A

Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client. Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.

3. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?

A. "I will assist you in arranging to have a medicine woman present."?
B. "We do not allow medicine women in exam rooms."?
C. "That does not make any difference in the outcome."?
D. "It is old-fashioned to believe in that."?

Correct answer: A

Rationale: The correct response is to show cultural awareness and acceptance by offering to assist in arranging for the medicine woman to be present. This demonstrates respect for the client's beliefs and preferences. Choice B is inappropriate as it dismisses the client's request without considering its cultural significance. Choice C is dismissive and does not acknowledge the client's values. Choice D is disrespectful and judgmental, undermining the client's beliefs. Therefore, the only appropriate and professional response is to support the client's request and offer assistance in accommodating it.

4. After assigning tasks, what is the nurse's primary responsibility?

A. Assigning any tasks that were not completed to the next nursing shift
B. Documenting completion of each task
C. Allowing each staff member to make judgments when performing the tasks
D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task

Correct answer: D

Rationale: The nurse's primary responsibility after assigning tasks is to follow up with each staff member regarding the task's performance and outcomes. This ensures accountability and quality care delivery. Allowing staff members to make judgments independently can compromise patient safety if they lack the necessary knowledge or experience. While documenting task completion is important, it should follow the follow-up to assess outcomes. Assigning incomplete tasks to the next shift is not ideal as it may result in unmet patient needs and increased workload for the next shift.

5. What is the appropriate intervention for a client who is restrained?

A. Remove the restraints and provide skin care every hour.
B. Document the condition of the client's skin every 3 hours.
C. Assess the restraint every 30 minutes
D. Tie the restraint to the side rails.

Correct answer: C

Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.