the client is being discharged to a long term care ltc facility the nurse is preparing a progress note to communicate to the ltc staff the clients out the client is being discharged to a long term care ltc facility the nurse is preparing a progress note to communicate to the ltc staff the clients out
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Nursing Elites

NCLEX NCLEX-RN

NCLEX RN Predictor Exam

1. The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should:

Correct answer: Draw conclusion about resolution of current client problems

Rationale: To effectively communicate the client's outcome goals that were met and those that were not to the LTC staff, the nurse should draw conclusions about the resolution of the current client problems. Terminal evaluation is performed to determine the client's condition at discharge, focusing on which goals were achieved and which were not. Formulating post-discharge nursing diagnoses (option A) is not the most appropriate action in this scenario as it focuses on identifying potential problems after discharge rather than evaluating achieved goals. Assessing the client for baseline data (option C) is not necessary at this point as the focus is on evaluating outcomes rather than collecting baseline data. Planning the care needed in the LTC facility (option D) is premature as this should be done on admission to the LTC facility and not during the discharge process.

2. A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior?

Correct answer: "My mother keeps trying to get me to eat."

Rationale: The statement "My mother keeps trying to get me to eat" indicates that the adolescent is experiencing secondary gains from her behavior. This is because the behavior has garnered attention from her mother, providing a sense of power and control, which are considered secondary gains. The statement "I'm huge; I'm as big as a house" reflects a disturbed body perception and is not related to secondary gains. Getting straight A’s in all subjects is an achievement but not a secondary gain related to anorexia nervosa. The hair falling out in clumps is a physical consequence of starvation, not a secondary gain.

3. The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?

Correct answer: Prone position

Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site. Therefore, the correct choice is the prone position for this postoperative care scenario.

4. The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?

Correct answer: The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg

Rationale: While all the values are abnormal, the low PaO2 level of 59 mm Hg indicates that the patient is at a critical point on the oxyhemoglobin dissociation curve. At this level, a small decrease in PaO2 can lead to a significant drop in oxygen saturation and compromise tissue oxygenation. Therefore, immediate intervention is necessary to improve the patient's oxygenation status. Choice A (HCO3 of 31 mEq/L) may indicate metabolic alkalosis or compensation for respiratory acidosis; however, it does not require immediate action in this scenario. Choice B (SaO2 of 92%) is slightly low but not critically low to require immediate action. Choice C (PaCO2 of 31 mm Hg) is within the normal range and does not indicate immediate danger to the patient.

5. A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant would most require the nurse's immediate intervention?

Correct answer: The nursing assistant elevates the head of the bed to 60 degrees for a meal

Rationale: After a coronary angiogram, patients need to maintain bed rest and keep the head of the bed at no more than 30 degrees for 3-6 hours, depending on the insertion site. Elevating the head of the bed to 60 degrees for a meal could increase the risk of bleeding or complications at the insertion site. Refilling the ice pack placed on the insertion site is appropriate for managing potential swelling or discomfort. Filling the patient's pitcher with ice-cold drinking water is a standard care task. Placing an extra pillow under the patient's head upon request is a comfort measure and does not pose a risk to the patient's recovery.

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