a health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospitals stoma nurse to visit the client and assist

NCLEX-PN

NCLEX PN Test Bank

1. A health care provider asks the nurse caring for a client with a new colostomy to request the hospital’s stoma nurse to visit the client and assist with colostomy care. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of which type of power?

A. Expert power
B. Referent power
C. Coercive power
D. Reward power

Correct answer: Expert power

Rationale: Power is the ability to influence others to achieve goals. Expert power results from knowledge and skills that one possesses that are needed by others. In this scenario, the stoma nurse's expertise in colostomy care gives them the ability to influence the client effectively. Reward power is based on the ability to grant rewards and favors, which is not applicable in this situation. Coercive power is based on fear and the ability to punish, which is not the case in seeking assistance for colostomy care. Referent power results from followers' desire to identify with a powerful person, which is not the primary influence in this context.

2. A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions?

A. ''Wood surfaces on the crib need to be free of splinters and cracks.''
B. ''I need to keep large toys out of the crib.''
C. ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.''
D. ''The drop side needs to be impossible for my infant to release.''

Correct answer: ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.''

Rationale: The correct answer is, ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.'' This statement indicates a need for further instructions as the distance between the slats should be no more than 2⅜ inches to prevent entrapment of the infant’s head and body, not 4 inches. Allowing a larger gap can pose a risk of entrapment or injury to the infant. Keeping large toys out of the crib is essential to prevent the infant from using them to climb out, which could result in serious injuries. Ensuring the drop side of the crib is impossible for the infant to release is crucial to prevent falls and injuries. Additionally, maintaining wood surfaces on the crib free of splinters, cracks, and lead-based paint is vital for the infant's safety and well-being.

3. What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?

A. Place the client in isolation until further assessment is completed.
B. Seclude the client from other clients and visitors.
C. Perform no intervention until test results confirm a diagnosis.
D. Don personal protective equipment immediately.

Correct answer: B: Seclude the client from other clients and visitors.

Rationale: The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.

4. What should a client room environment include?

A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)

Correct answer: a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.

Rationale: A client room environment should include a made bed to provide a sense of neatness and comfort, ensuring the client's safety at all times. It is important to maintain a clutter-free area to prevent accidents and promote a relaxing environment. Having hygiene articles nearby allows the client easy access to personal care items. Choice A is incorrect because while fresh water and thermostat regulation are important, they are not essential components of a client room environment. Choice C is incorrect as it emphasizes more on cleaning procedures rather than creating a comfortable and safe environment for the client. Choice D is incorrect as it emphasizes odor control and storage rather than the client's comfort and safety.

5. Which of the following medications should be held 24–48 hours prior to an electroencephalogram (EEG)?

A. Lasix (furosemide)
B. Cardizem (diltiazem)
C. Lanoxin (digoxin)
D. Dilantin (phenytoin)

Correct answer: Dilantin (phenytoin)

Rationale: Anticonvulsants like Dilantin should be held 24–48 hours before an EEG to prevent interference with the test results. Medications such as tranquilizers, barbiturates, and other sedatives should also be avoided. Lasix, Cardizem, and Lanoxin do not belong to these categories and are not known to interfere with EEG results.