nclex rn

  1. 117. Of the tasks listed, which would be considered an intermediate priority?1. a patient post-extubation that O2 stats are ranging from 83–88 percent2. a post-op patient with a colon resection whose wound dehisced3. an elderly patient with chronic diarrhea for three weeks4. a patient that pulled out her central line and is bleeding
    (3) The elderly patient with chronic diarrhea for three weeks would be categorized an intermediate priority in the contextof the other answer choices. The diarrhea needs to be addressed as it is a significant problem with potential risksand negative consequences; however, the other situations would command high-priority attention.
  2. 118. An 85-year-old female resident (Mrs. A) who has Alzheimer’s disease is extremely upset because she can’t findher clothes. She comes to the nurse’s station in tears, hyperventilating and shaking. You are in the midst ofassessing and treating another resident (Mr. B) with COPD, who is having breathing problems, and you are inthe process of setting up oxygen therapy ordered and a nebulizer treatment with albuterol. What becomes yourimmediate top priority?1. Stay focused on treating Mr. B.2. Set aside the respiratory treatments and go and help Mrs. A find her clothes.3. Explain to Mrs. A that her clothes are not missing.4. Ask a nursing assistant passing by in the hallway to assist Mrs. A and focus on the treatments orderedfor Mr. B.
    (4) Your nursing priority in this case should be dealing with Mr. B who is physiologically unstable. However, Mrs. B’spsychological distress should not be considered less important. Delegating the task of providing assistance to Mrs. A tothe nursing assistant will help to meet her immediate needs for attention and buy some time for you to address Mr. B’sproblem.
  3. A low-priority patient concern:1. is one that is optional to address.2. is the priority problem for the patient, not the nurse.3. needs that may not be related to a specific illness or problem being treated.4. is one that is not important in the overall quality of patient care.
    (3) The nurse has an obligation to assist a patient in meeting their needs. Low-priority concern may still be significantin the overall picture and deserve the nurse’s attention at some point.
  4. 120. An important aspect to consider when dealing with a low-priority concern is:1. the patient’s agreement that it is a low priority as well.2. cost-benefit.3. available resources.4. all of the above.
    (4) All aspects should be considered in dealing with a patient’s concern that is considered a low priority.
  5. 121. The nursing diagnosis “risk for infection” related to a 50–pack-per-year history of smoking would be considered:1. a low priority.2. an intermediate priority.3. a high priority.4. priority decision depends on the care setting.
    (1) This would be considered a low priority as it reflects the client’s long-term health needs.
  6. 122. According to the ANA Code for Nursing, professional nurses have an ethical obligation to:1. clients (patients).2. profession of nursing.3. provide high quality care.4. all of the above.
    (4) Quality of care, professional standards, and patient-centered care are all elements of the ANA Ethical Code forNurses.
  7. 123. The ethical principle of keeping professional promises or obligations is:1. veracity.2. autonomy.3. fidelity.4. beneficence.
    (3) The ethical principle of veracity is truth telling. Autonomy is patient self-determination (that is, patients makingtheir own decision). Beneficence is the principle of “doing good,” which is a foundation of nursing care.
  8. 124. Issues addressed in ethics committees include all of the following except:1. nonpayment of bills.2. euthanasia.3. starting or stopping treatment.4. use of feeding tubes.
    (1) Ethics committees do not deal with financial matters of payment. Euthanasia, stating or stopping treatment, and theuse of feeding tubes to maintain nutritional status are topics within the ethical scope of the committee’s function.
  9. 125. The ethical principle of nonmaleficience is:1. doing good.2. freedom of choice.3. do no harm.4. truth telling.
    3) Nonmaleficience is the ethical principle of “doing no harm,” which the main concept of medicine’s Hippocratic Oath.The ethical principle of beneficence is “doing good.” Freedom of choice is patient autonomy. Veracity is truth telling.
  10. 126. The purpose of ethics committees is to:1. have legal authority.2. satisfy JCAHO requirement of all hospitals.3. provide education and guide policy making regarding clinical issues.4. provide healthcare personnel with legal protection from lawsuits.
    (3) Ethics committees are formed in order to provide a resource to patients, families, and staff. They are not a requirementof JCAHO; many small hospitals do not have them. Committee work/decisions are presented as recommendationsand are not considered “law.” Their purpose does not include determination of innocence versus guilt; thus, their actiondoes not imply legal protection.
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nclex rn