a client with a spinal cord injury is preparing to return home from the rehabilitation unit which of the following statements by a family member indic

NCLEX-PN

NCLEX PN Test Bank

1. A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?

A. "I should raise him to a sitting position."?
B. "I should check for a fecal impaction."?
C. "I should look for a kink in the urinary catheter tubing."?
D. "I should observe whether symptoms worsen."?

Correct answer: D

Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.

2. Which NSAID is comparable to morphine in efficacy?

A. Feldene
B. Stodal
C. Toradol
D. Elavil

Correct answer: C

Rationale: The correct answer is Toradol. Toradol is the first injectable NSAID that has been found to be comparable to morphine in terms of efficacy. Feldene (choice A) is not known for being comparable to morphine in efficacy. Stodal (choice B) is a homeopathic cough syrup and not an NSAID. Elavil (choice D) is a tricyclic antidepressant and not an NSAID, so it is not comparable to morphine in efficacy. Therefore, Toradol is the most appropriate choice as it matches the description provided in the question.

3. During an emergency procedure, is the surgical timeout a requirement?

A. The surgical timeout should be performed by the surgical team unless it would cause a delay leading to injury or death.
B. No, the timeout is not necessary during an emergency procedure.
C. No, the surgical timeout is not required in emergency procedures.
D. Yes, the surgical timeout must be performed in all cases.

Correct answer: A

Rationale: During an emergency procedure, the surgical timeout should be performed unless doing so would cause a delay leading to injury or death. This is because the primary goal during an emergency is to swiftly address the critical situation. Choice B is incorrect as it implies that the timeout is not necessary, which is not accurate. Choice C is also incorrect as it suggests that the timeout is not required in emergency procedures, disregarding safety protocols. Choice D is incorrect as it wrongly states that the timeout must be performed in all cases without considering the potential risks associated with delays during emergencies.

4. A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?

A. Keeping the door to the client's room closed
B. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times
C. Placing the client in a semiprivate room with a cohort client
D. Using a surgical mask when entering the client's room

Correct answer: A

Rationale: Evidence-based practice is an approach to client care that integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. In the case of pulmonary tuberculosis, which is transmitted through the airborne route, keeping the door to the client's room closed is crucial to prevent the spread of infection. Placing the client in a semiprivate room with a cohort client is not recommended for airborne precautions; a private room is required to prevent transmission. Fitting the client for an N95 or HEPA mask is essential for the nurse's protection when entering the room, not for the client to wear at all times. Using a surgical mask when entering the client's room is not sufficient for airborne precautions; an N95 or HEPA mask is necessary.

5. A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?

A. Ignoring the situation
B. Documenting the problem in the nursing assistant's personnel file
C. Asking other staff members to cover for the nursing assistant
D. Meeting with the nursing assistant to discuss the behavior and initiate problem-solving measures

Correct answer: D

Rationale: Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (Choice A), asking other staff members to cover (Choice C), or documenting the problem in the nursing assistant's personnel file (Choice B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.