the nursing staff has a normal nurse to client ratio of three clients per nurse on the floor nurse ann tells nurse christine that one of her clients s the nursing staff has a normal nurse to client ratio of three clients per nurse on the floor nurse ann tells nurse christine that one of her clients s
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Nursing Elites

NCLEX NCLEX-PN

Nclex PN Questions and Answers

1. Nurse Ann tells nurse Christine that one of her client’s status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?

Correct answer: Nurse Christine should inform their supervisor that assignments may need to be changed.

Rationale: In this situation, when Nurse Ann informs Nurse Christine that a client's status is declining and she needs to attend to them, the most appropriate action for Nurse Christine is to inform their supervisor that assignments may need to be changed. By informing the supervisor, necessary adjustments can be made to ensure proper care for all clients. Offering to give medications to Nurse Ann’s other two clients (choice A) may not address the underlying issue of a declining client and could lead to a delay in care. Asking other nurses for help (choice C) might not be the most efficient solution, as the supervisor is responsible for reassigning tasks. Nurse Ann continuing to care for all her assigned clients (choice D) may compromise the quality of care provided to the declining client and may spread her too thin, impacting all clients negatively.

2. While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?

Correct answer: Notify the healthcare provider

Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.

3. A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?

Correct answer: The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge

Rationale: The correct answer is A. A care map, also known as a critical pathway, outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge or the end of a treatment phase. It includes clinical assessments, treatments, dietary interventions, activity therapies, client education, and discharge planning. While it may identify nursing diagnoses, a care map is developed by all disciplines caring for the client type and is used by the interdisciplinary team, not just the nurse alone. Choice B is incorrect because a care map is not solely for the nurse but for the entire interdisciplinary team. Choice C is incorrect as care maps are individualized plans developed by the interdisciplinary team, not just by a nurse. Choice D is incorrect as a care map is not solely about nursing diagnoses but encompasses a comprehensive plan of care.

4. While reviewing a client’s health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client’s bowel sounds?

Correct answer: Hyperactive bowel sounds

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

5. Which of the following is not considered one of the five rights of medication administration?

Correct answer: routine

Rationale: The five rights of medication administration are dose, client, drug, route, and time. The correct answer is 'routine' as it is not commonly recognized as one of the essential rights in medication administration. Choice A, client, is necessary to ensure the right medication is administered to the right individual. Choice B, drug, is crucial to confirm the correct medication is given. Choice C, dose, is essential to ensure the right amount of medication is administered. Choice D, routine, is not typically included in the five rights of medication administration and is therefore the correct answer.

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