NCLEX Practice Questions — Set 30
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
Which of the following should the nurse include in the instructions given to an older adult about self-care and hygiene to achieve a positive outcome?
Show answer and rationale
Correct answer: A. A written description of the outcomes
By giving the client a written description of the expected outcomes and then explaining the procedures and demonstrating the techniques, the nurse will facilitate learning and mutual goal setting.
The nurse evaluates which factor as a priority that will adversely affect mobility and self-care in the older adult?
Show answer and rationale
Correct answer: C. Weakness
Older adults may have many chronic conditions that do not affect mobility or selfcare. Weakness from any cause often means that older adults cannot be mobile and care for themselves.
Older clients have individual preferences in carrying out activities of daily living (ADLs). The nurse should include which intervention as a priority for encouraging independence in ADLs?
Show answer and rationale
Correct answer: D. Assess the client’s abilities and preferences
It is not advised to ask older clients when they want to take a bath because they may refuse activities of daily living (ADLs). Even clients who are handicapped are capable of autonomy and self-care. Asking the client what ADLs are acceptable to perform promotes dependency. Assessing the client’s abilities, setting mutual goals, and planning care accordingly promote independence in the client.
The nurse finds an 88-year-old client lying on the floor unresponsive. The priority action for the nurse to take is
Show answer and rationale
Correct answer: A. assess the respirations and pulse.
When finding a client unresponsive on the floor, the priority is to assess the respirations and pulse before notifying the physician or starting cardiopulmonary resuscitation (CPR).
When planning to interview an older adult for a health history, the nurse should consider which of the following as a priority?
Show answer and rationale
Correct answer: A. The goals of the interview vary
The interview for a health history should identify past and present problems. It should be conducted in a private environment, and the client’s room may not be private. The interview is not for the purpose of offering solutions to the problems. Depending on the setting and the reasons why the nurse is conducting the interview (such as to assess an acutely ill client or to evaluate a client still living at home who has a chronic condition), the goals may vary.
The registered nurse is planning clinical assignments for a geriatric nursing unit. Which of the following assignments should the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: D. Take the vital signs of a 71-year-old client following a hip arthroplasty
A licensed practical nurse may take the vital signs on a client following a hip arthroplasty. Assessing, monitoring, and performing a physical assessment are all skills that require a registered nurse.
The nurse has determined that a confused older adult client who keeps pulling out the intravenous line and indwelling catheter is in need of soft wrist restraints. Which of the following should the nurse include in this client’s plan of care?
Show answer and rationale
Correct answer: B. Assess the placement of the wrist restraints, skin, and circulation every hour and document
The standard of care for restraints is that they can be applied only with a written order from a health care provider. The order must be renewed every 24 hours. A p.r.n. order for restraints is not acceptable. Restraints should be removed once every 2 hours to perform activities of daily living. The client with wrist restraints should be placed in a lateral position to prevent aspiration. The condition of the skin, circulation, and placement of restraints must be assessed every hour. The assessment must also be documented.
A family expresses concern to the nurse when their 96-year-old mother with dementia living in a long-term care facility seems more confused and does not remember the activities of daily living. Which of the following is the most appropriate response?
Show answer and rationale
Correct answer: B. "This must be frustrating for you."
When a family expresses concern over their mother’s confusion and decreased ability to perform her activities of daily living, the most appropriate response to the family is to acknowledge how frustrating it must be for the family. The nurse should not minimize family members’ feelings or tell them how to feel. Reminding a client with short-term memory loss may increase agitation. Although the dementia will progress over time, reinforcing that with the family is a negative response and may shut down communication.
A 77-year-old client expresses concern to a nurse in a walk-in psychiatric clinic of "going crazy or of having Alzheimer’s disease" because of feelings of being overwhelmed and sad all of the time, and misplacing things. Which of the following is the priority for the nurse to include in this client’s plan of care?
Show answer and rationale
Correct answer: A. Make a psychosocial assessment
The first step of the nursing process is assessment. Before helping the client deal with a problem or exploring available resources, the nurse should determine if a problem is really present. Assuring the client and dispelling the idea of "going crazy" are negative interventions, and the nature of this client’s condition is not yet known.
Upon admission to a long-term care facility, an 83-year-old client is withdrawn, sitting quietly in a chair with the back to the door of the room. When the nurse speaks to the client, the client says, "Go away and leave me alone. Spend your time on someone who can use it. I just don’t want to live if I have to stay here." Which of the following is the priority nursing action?
Show answer and rationale
Correct answer: D. Assess for depression and suicide potential
Although creating a cheerful environment is important in a long-term care facility, the priority intervention is safety. Older adults who express not wanting to live if they have to stay there may be clinically depressed and at risk for self-harm. Encouraging clients to discuss feelings of hopelessness and allowing for periods of solitude may be appropriate interventions, but are not the priorities.
An 86-year-old client suddenly becomes confused about time, place, and person. After evaluating the oxygen saturation to be 98%, which of the following should the nurse assess first?
Show answer and rationale
Correct answer: D. Vital signs
In the case of delirium and a sudden change in mental status, the nurse should always assess for physiological causes-airway, breathing, and circulation-first. Although medications the client is taking, a recent fall, or the client’s pain level may be possible causes of the delirium, the vital signs should be assessed first.
A 56-year-old client diagnosed with Stage I (early-onset) Alzheimer’s disease lives at home with family. A daughter asks the nurse, "How long will Dad be like this before his memory returns?" The best initial response the nurse can make is which of the following?
Show answer and rationale
Correct answer: A. "Tell me what you know about Alzheimer’s disease."
The best response when the family of a client diagnosed with Stage I (early-onset) Alzheimer’s disease asks when the family member will get better would be to ask family members how much they know about Alzheimer’s. This is the best response because it facilitates open communication. Although the disease has a progressive course, telling the family that will close communication. Asking the family member if the client is taking medication for Alzheimer’s disease is an inappropriate response, because it changes the subject.
An older adult is picking at clothing and muttering, "Butterflies are all over me." The nurse does not see any butterflies. Which of the following is the priority for the nurse to perform?
Show answer and rationale
Correct answer: D. Identify any risk for injury related to altered thought processes
The first nursing action should be to identify any risks to the client or others because of the alteration in thought processes that the client is experiencing. It may be appropriate to provide a nonstimulating environment, but that is not the priority. Informing the client that there are no butterflies might precipitate a catastrophic reaction.
An older adult’s cognitive function has declined over the last 2�years. The family is concerned by the loss of short-term memory and the safety issues posed by the forgetfulness. A complete medical workup including a computerized tomography (CT) scan of the head has shown no medical cause for the cognitive changes. The nurse explains to the client and family that the medical diagnosis of Alzheimer’s disease is based on
Show answer and rationale
Correct answer: A. the information that no other cause can be found for the changes.
The definitive diagnosis for Alzheimer’s disease is only found on autopsy. When all other possible causes of cognitive decline are ruled out, the medical diagnosis of Alzheimer’s disease (or Alzheimer’s-like disease) is made. The Mini-Mental State Exam is one of many short tests to measure cognitive function, but it does not actually diagnose dementia. The older adult will show a decrease in the mass of the brain but may not have a corresponding loss of cognitive function. A blood test for C-reactive protein would not be positive for Alzheimer’s disease.
When assessing an older adult, the nurse should be alert to the clinical manifestations of depression that may be masked by other chronic conditions. The cardinal and primary behavior exhibited in the depressed older adult is
Show answer and rationale
Correct answer: B. a loss of interest in previously pleasurable activities.
Loss of interest in previously enjoyable activities and withdrawal are indicators to the nurse that the client may be clinically depressed and in need of further assessment. Inactivity, drinking alcohol, and crying may be indicative of depression or other chronic conditions, not just depression.
Before preparing to use the Mini-Mental State Exam for cognitive function in an older adult, the nurse should consider which of the following limitations of the exam?
Show answer and rationale
Correct answer: B. The client must be able to see and write
The Mini-Mental State Exam does not require a specially trained individual and requires only 20 to 30 minutes to administer. The client must be able to see and write because the client will be asked to write a sentence as well as to copy a drawn figure.
The nurse should consider which of the following medical etiologies in an older adult who has been healthy until recently but has developed dementia?
Show answer and rationale
Correct answer: D. Sexually transmitted diseases
The first indication that a client has a sexually transmitted disease such as tertiary syphilis or HIV may be cognitive function changes and dementia.
Which of the following four older adult clients that the nurse is caring for does the nurse evaluate as most at risk for self-directed violence?
Show answer and rationale
Correct answer: C. A widowed man who is 88�years old, lives alone, and has multiple chronic illnesses
Older women, even if depressed, tend to be less likely to harm themselves, because they have social support and other interests. Older men without social support who have multiple chronic illnesses and live alone are more likely to commit suicide than older women.
An older adult client with chronic depression tells the nurse, "Don’t worry about me. I can manage the pain of my arthritis. The way I mix up my medications helps." The best initial response by the nurse is which of the following?
Show answer and rationale
Correct answer: B. "Tell me what you take and how you mix them."
Clients with chronic illnesses and pain often adjust their own medications or add over-thecounter medications. A client’s depression could be a result of the drugs or it could be the reason the client mixes medications. The nurse needs further information to identify risks for injury.
The nurse is caring for an older adult with situational depression following the death of a spouse. What is the most important outcome for the nurse to plan for?
Show answer and rationale
Correct answer: D. The client will discuss the spouse and the meaning of the loss
It is most appropriate for the nurse to encourage clients who are experiencing situational depression over the loss of a spouse to verbalize their feelings. Crying is a normal and healthy expression of loss. The relationship with the spouse may not always have been positive, or the client may feel angry about the death. Setting an outcome that the client will speak positively describes how the client should feel and is not necessarily true.
Which of the following is the priority nursing intervention for the nurse to include in the plan of care for a client with behavior problems related to dementia?
Show answer and rationale
Correct answer: A. Instruct the caregivers on the process of dementia and care to be given
Educating the caregivers, whether family members or others, is always the priority when caring for a client with dementia. The caregivers must understand the disease and expected behaviors as well as the interventions for problem behaviors. The same interventions may not be effective as the condition changes. This should be part of the continued evaluation and part of the replanning.
A nurse observes a family member continually reminding a client in late Stage II Alzheimer’s disease of the date and place. The client is adamant that it is 1922 and the North Pole. The nurse informs the family member that continually reminding the client of the date and place will result in
Show answer and rationale
Correct answer: D. a catastrophic reaction.
In late Stage II Alzheimer’s disease there is no hope for memory return. Repeating reality orientation for the client whose reality is different may cause anxiety, anger, agitation, and a catastrophic reaction, such as running away or violence.
An 80-year-old client is admitted to the intensive care unit because of hemorrhaging after a stent is placed in her left femoral artery to improve circulation to the leg. The client is confused, not following instructions, and pulling at the intravenous tubing and indwelling catheter. The client’s adult son tells the nurse, "My mom was never like this before. What have you done to her?" The best initial response the nurse can make is which of the following?
Show answer and rationale
Correct answer: D. "Older adults will become confused after a bleed to the brain from decreased oxygen."
Older adult clients may become confused after a bleed to the brain from decreased oxygen. Telling the family that the medical team has done nothing to the client is a defensive statement and would cut off communication. Dementia is a medical diagnosis, which the nurse does not make. The best initial response by the nurse is to answer the son’s question. The nurse may need to know if the client has an alcohol abuse problem, but not until the son’s concerns are answered. Passing the son off to the physician at this point would shut down communication with the son.
An older client in a nursing facility suddenly becomes confused, paranoid, and verbally abusive to the staff. Which of the following is the priority nursing action?
Show answer and rationale
Correct answer: C. Assess the vital signs and obtain a urine specimen
Assessing the vital signs and obtaining a urine specimen is the priority in an older client who suddenly becomes confused and develops psychotic behavior. A urinary tract infection would be evident from an elevated temperature and bacteria in the urine specimen.
An older adult client with dementia becomes increasingly confused and wanders away from a long-term facility. The appropriate nursing action is to
Show answer and rationale
Correct answer: A. follow the client and redirect from a safe distance.
When a client with dementia wanders away from a long-term care facility, the nurse should see if the client will return willingly with persuasion and redirection. If the client will not return, notifying law enforcement may be necessary, but the presence of law enforcement officials may also agitate and frighten the client. At no time should the nurse physically restrain the client alone or transport a client.
Which of the following should the nurse include in the education provided to a new graduate nurse to protect the nurse from injury when a client with dementia or delirium becomes aggressive?
Show answer and rationale
Correct answer: C. Provide a quiet, calm atmosphere and offer simple directions
Touching an agitated client may increase aggression and precipitate violence against the nurse. The client should be in a quiet, calm atmosphere away from others and simple directions should be offered. Offering a meal may work as a temporary distraction, but the client at this point will be unable to sit and follow instructions about eating.
Donepezil hydrochloride (Aricept) is prescribed for an older adult with early dementia, Alzheimer’s-like disease (ALD). When reviewing the client’s medical conditions and medications, the nurse notifies the physician that there might be a serious interaction because the client has
Show answer and rationale
Correct answer: C. bradycardia.
Aricept is a cholinesterase inhibitor used in the treatment of Alzheimer’s disease, which may cause bradycardia with fainting.
Rivastigmine (Exelon) is prescribed for a client with dementia. Which of the following would be an appropriate outcome of nursing care specific to this drug?
Show answer and rationale
Correct answer: C. The client will maintain a weight within the normal range
Rivastigmine tartrate is used in the treatment of mild to moderate Alzheimer’s disease. Nausea, vomiting, anorexia, and abdominal pain are adverse reactions to Exelon. The nurse should monitor weight weekly. Eating 50% of the food offered may not be sufficient to maintain body weight.
The registered nurse is planning the clinical assignments for a geriatric mental health unit. Which of the following assignments should the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: A. Administer donepezil hydrochloride (Aricept) to a client newly diagnosed with Alzheimer’s disease
A licensed practical nurse may administer donepezil hydrochloride (Aricept) to a client with Alzheimer’s disease. Developing a plan of care, performing a physical assessment, and providing education to a client’s family on dementia are tasks that should be performed by a registered nurse.
The nurse working as a case manager understands that case management is often needed when the client
Show answer and rationale
Correct answer: B. has complex acute or chronic health care needs.
Case management is a process used to assist individuals with complex health care problems by providing quality care with a cost-effective outcome. It organizes client care through a health care problem meeting, so that specific clinical and financial outcomes are achieved within a designated time period.
A client’s family asks the nurse what the case manager’s primary goal is. The most appropriate response of the nurse is to
Show answer and rationale
Correct answer: B. promote self-care of the client whenever possible.
The goal of case management is to help the client care for him- or herself. The case manager is responsible for coordinating care and establishing goals, from the admission phase through to discharge. The case manager works with all disciplines to facilitate care.
A nurse has just accepted the position as a case manager at a local hospital. According to the definitions of various professional organizations that work with case managers, case management is a(n)
Show answer and rationale
Correct answer: D. collaborative process between various health care providers.
Case managers do not usually work alone, but instead work with various health care team members to provide care for the client. Case management promotes collaboration, communication, and teamwork to provide the best possible care for the client in the most cost-effective manner possible. Case management also promotes timely discharge.
A nurse is teaching a class about the history and development of case management. The nurse includes the information that case management developed as the result of many factors, such as which of the following?
Show answer and rationale
Correct answer: C. Health care resources are scarce, so valuable resources must not be wasted.
Although health care resources are limited, case managers work to use these resources to provide quality care cost-effectively and to promote timely discharge.
The nurse who has always used the nursing process when planning client care has just taken a position utilizing case management. Based on an understanding of the nursing process and the case management concept, the nurse understands that case management
Show answer and rationale
Correct answer: D. follows a process very similar to the nursing process.
Case management follows a process very similar to the nursing process and includes assessment, planning, implementation, and evaluation.
A nurse applied for a case manager position at the local hospital because the job description of the case manager is to
Show answer and rationale
Correct answer: A. help clients determine the best care for the least cost.
Hospitals needed a mechanism to find high-quality, cost-effective care to meet client needs. Case managers can assist the hospital and the clients to reduce the costs of care and ensure that a high quality of care will be provided.
Which of the following would a school nurse perform when functioning as a case manager?
Show answer and rationale
Correct answer: A. Team teach a class on healthy after-school snacks
The focus of case managers in schools is to provide services for the enrolled students that improve health care. Teaching a class on healthy after-school snacks would provide such a service. Meeting with the newspaper office or contacting the school board does not focus directly on improving the health of the students. Disciplining children in sports who do not adhere to weight-maintenance guidelines is a punitive action and would not be performed by the nurse.
In evaluating the nurse’s role as a case manager, the nurse would determine which of the following skills as most beneficial in caring for clients?
Show answer and rationale
Correct answer: A. An ability to solve complex problems in a creative way
Because the case manager must solve problems for clients in unique situations usually outside of the hospital setting, protocols may not be well established or in written form. The case manager must be flexible and creative in order to solve these problems. Having worked in an environment where established protocols and procedures were closely followed will also help the nurse now working as a case manager.
The case manager nurse should be assigned to provide services to which of the following clients?
Show answer and rationale
Correct answer: D. A client with newly diagnosed diabetes mellitus
Case managers usually work with clients who have complex or newly diagnosed conditions, such as a client newly diagnosed with diabetes mellitus.
Which of the following is the priority for the nurse case manager planning the discharge of a client who is hospitalized for bone cancer?
Show answer and rationale
Correct answer: C. Transfer the client’s care to another case manager in the community setting
Continuity of care is important in the care of clients. Because the hospital case manager may not be able to follow the client at home, it is a priority that the care of the client be transferred to a community case manager upon discharge.
In caring for a client with a terminal condition, the nurse understands that the case management role in the hospital
Show answer and rationale
Correct answer: B. begins when the client receives the diagnosis of cancer.
The case manager should be involved from the time that admission of the client and the process of case management are implemented, shortly after the diagnosis has been made. This ensures that multiple services are provided in an efficient and cost-effective manner.
A client has recently been hospitalized for open heart surgery and is going to be transferred to a skilled care facility for additional recovery. Which of the following is the role of the nurse case manager in the hospital?
Show answer and rationale
Correct answer: C. Arrange transportation to the new facility
As a case manager, the nurse should help arrange the transition to the new facility, including transportation, transferring orders for medications and activities, and encouraging family involvement in the transfer. Equipment and volunteers needed in the home would not be arranged at the time of transfer. The new facility would be responsible for obtaining any pharmaceutical supplies.
The nurse is screening a client with mild dementia who is unsafe in the home and needs minimal assistance with activities of daily living. The nurse should recommend which of the following facilities as the most appropriate placement for this client?
Show answer and rationale
Correct answer: C. Assisted living
An assisted living facility is designed for a client who can no longer stay in the home and who needs only minimal assistance with activities of daily living or medication monitoring. A subacute care unit provides skilled nursing care 24 hours a day for a client with advanced dementia and who needs maximum assistance with activities of daily living. A rehabilitation unit provides specialized therapies, such as speech or physical therapy, for clients with neurological impairments who can return to the home environment after a period of rehabilitation lasting several weeks to months. Skilled nursing care would be necessary if a client needs care 24 hours a day in a structured environment, such as a nursing home facility.
Discharge plans are being made for a 74-yearold client who is widowed, lives alone, and had a left hip arthroplasty after a fall on the ice when volunteering in a day care. Which of the following facilities should the nurse discharge this client to?
Show answer and rationale
Correct answer: B. Rehabilitation unit
It is most appropriate to discharge an older client who had a hip arthroplasty and was independent, living alone, and still working as a volunteer to a rehabilitation unit. The goal of a rehabilitation unit is to return the client to the maximal level of functioning possible and to the home environment.
The registered nurse is preparing the work schedule at a skilled nursing care facility. Which of the following work assignmentswould be appropriate for the registered nurse to include?
Show answer and rationale
Correct answer: C. A licensed practical nurse will be on duty on all three shifts daily
A licensed practical or vocational nurse (LP/VN) should be on duty 24 hours a day, 7 days a week in a skilled nursing facility. Unlicensed assistive personnel cannot administer drugs. A certified medication aide (CMA) is a certified nurse aide who has taken an additional course on medication administration and may administer medications in some states. It is essential that the nurse making assignments know the law in the resident state. A certified medication aide cannot perform dressing changes and is not allowed to perform nursing care beyond personal care and activities of living.
The nurse assesses an older client in an assisted living facility who is crying uncontrollably and who tells the nurse, "I am going to be evicted because I ran out of money to live here." Which of the following is the priority response by the nurse?
Show answer and rationale
Correct answer: C. "There are other financial options available to you."
The priority response for the nurse to make to a client who has exhausted all personal financial resources in an assisted living facility is that there are other options available. Those other options may include family support or Medicaid. The nurse is not in a position to discuss or advise the client about financial matters. A financial advisor would be the best person to advise the client.
Which of the following should receive priority when the nurse is developing the plan of care for an older client in a skilled nursing care facility?
Show answer and rationale
Correct answer: D. The client’s ethnic origin
Although the client’s age, ethnic origin, financial resources, and physical and mental status are all important to consider when developing a plan of care for an older client in a long-term care facility, the priority is to consider the client’s ethnic origin. Admission to a long-term care facility is viewed differently by people from different cultures, and the client’s acceptance and perception of the long term will have a direct impact on the plan of care.
The nurse is teaching a class on long-term care. Which of the following should the nurse include in the lecture?
Show answer and rationale
Correct answer: B. The annual cost of a long-term care facility for one client can be $40,000
The annual expense for long-term care is very costly and may be in excess of $40,000. Approximately two out of every five individuals will need some kind of long-term care at some point in life. Medicaid and out-of-pocket payments are the primary methods of paying for long-term care. A client does not have to remain medically or psychologically stable to keep long-term care insurance. When choosing a long-term care insurance policy, it is essential that the policy include coverage for Alzheimer’s disease and other forms of dementia.
An older adult client asks the nurse about the�difference between Medicare Part A, Medicare Part B, and Medicaid. The appropriate response by the nurse is which of�the following?
Show answer and rationale
Correct answer: B. "Medicaid is granted for low-income clients�who receive a Social Security benefit."
Medicare Part A covers hospitalization. Medicare Part B covers outpatient and physician services. Medicaid is a federally and state-funded health care program for low-income clients. Physician services, eye and dental care, prescriptions, and preventive services are covered under Medicaid.
A nurse has been asked to teach a class about home health care to a local church group. Which of the following points should the nurse include in a class on home health care? Home health care
Show answer and rationale
Correct answer: A. was formally organized by visiting nurses in the late 1800s.
Home care was the primary source of care for many years. It began with charities, but was formally organized by visiting nurses in 1877 in New York. Medicare has helped provide a regular source of funding since Medicare began in 1965.
The nurse is establishing a home health care agency and knows it is important to understand the influence Medicare has had on the development of home health care because
Show answer and rationale
Correct answer: B. Medicare provided a regular source of funding for home health care.
Medicare is made up of two parts: Part A, or the hospital insurance, and Part B, or the supplemental medical insurance. Prior to Medicare, most home care was provided by voluntary agencies. In 1965, Medicare legislation was passed and provided a source of funding for home care.
When meeting with a client for the first time, the nurse working in home health care should include which of the following when describing the services that will be provided for the client?
Show answer and rationale
Correct answer: C. Care of the acute and chronically ill at home
People are often discharged from the hospital before they are well enough to take care of themselves. Home health care is considered a cost-effective way to provide care to clients with acute or chronic illnesses in their own homes.
Which of the following should the home health nurse include when providing home health care for a client?
Show answer and rationale
Correct answer: A. Plan visits based on client needs
The care for each client is planned by the nurse and based on an assessment of each client’s individual needs. The home care agency is responsible for billing the client and paying the nurse. The nurse provides skilled nursing care, not custodial care.
Which of the following factors should the home health care nurse consider when planning care for a client in the home?
Show answer and rationale
Correct answer: A. The family should be included in all care rendered in the home
When in the home, the client and family members must all be included in any care provided. Working in the home assists the nurse to see how the client functions within the family setting and the home environment.
A home health care nurse should include which of the following when informing a client about home care service?
Show answer and rationale
Correct answer: C. Greater autonomy and control over self-care are fostered
Home care is a cost-effective way of meeting the client’s needs in the comfort of the client’s home, including the adaptation of high-tech equipment to the home environment. Clients are usually more satisfied with and have more control over the care given in their homes than the care given in institutions.
When meeting with a client to explain the role of the nurse in home care, which of the following advantages of home care should be explained to the client? Home care
Show answer and rationale
Correct answer: B. provides a holistic view of the client that helps the nurse to establish appropriate goals and to plan appropriate care.
Home care provides a holistic view of the client that influences the client’s health. Being in the home environment provides an opportunity for the client to exercise more autonomy and control over personal care and encourages the client to function at the highest level of independence possible.
The nurse should consider which of the following when interviewing for a position as a home health care nurse at an official agency? The care is
Show answer and rationale
Correct answer: A. funded by tax dollars at the state or local level.
Official agencies are publicly funded by taxes and operate in state or local health departments that fall under the control of local health departments. Being an official agency does not guarantee certification by Medicare. The agency must still qualify for Medicare certification.
When a client calls a nurse who has established a private nonprofit home care agency in the community, the nurse should explain that nurses at the agency
Show answer and rationale
Correct answer: A. may receive funding from voluntary agencies, such as the United Way.
Private nonprofit agencies are governed by a board of directors and often receive funding from voluntary agencies. The agency, not the employees, has a tax exempt status. Proprietary agencies have stockholders who are concerned about making a profit.
A nurse working in a hospital-based home care agency is presenting the annual report to thehospital board. The nurse states, "In order for the hospital to operate this home care agency,
Show answer and rationale
Correct answer: C. the primary source of referrals comes from the inpatient population."
Most institutional-based agencies are operated and funded by hospitals and are governed by the hospital’s board of directors. The hospital expects the home care agency to serve as a source of revenue by providing home care for inpatients after discharge.
The home care nurse is assigned to change the dressing of a 78-year-old client following an emergency gallbladder surgery. The client asks the nurse if the home services will be covered by Medicare reimbursement. The most appropriate response by the nurse is which of the following?
Show answer and rationale
Correct answer: B. "Your home care will be covered because your physician certified you as homebound."
In order to qualify for reimbursement of home health care, the physician must certify that the client is homebound and requires skilled nursing care. Medicare only covers a client overthe age of 65�years or a client who is permanently disabled. Outcome and Assessment Information Set (OASIS) is a mandated federal requirement for all home health agencies. Its purpose is to measure outcomes for outcome-based quality improvement. Data must be collected at admission and every 60 days until discharge.
The local hospital has contacted a new home health agency in the community to identify what services the agency can provide. Which of the following services would be appropriate for the nurse to include in the examples given to the hospital of care that is available?
Show answer and rationale
Correct answer: B. Follow-up on three cases of tuberculosis in the local community
The home health nurse might be involved in case finding and follow-up that may impact the health in the community. The home health nurse is usually not involved in screening, teaching, or managing in specific organizations.
A public health nurse and a home health care nurse are meeting to discuss their roles in the community. The home health care nurse states that the nurse’s role in home health care focuses on
Show answer and rationale
Correct answer: C. illness care in the home.
Home health care focuses on illness care in the home and post-hospital follow-up. Public health focuses on health promotion and prevention in the community.
When planning the home care for a client who has returned home after suffering a stroke, the home health nurse should plan to supervise which of the following?
Show answer and rationale
Correct answer: C. The home care aide who assists the client with personal cares
Although the home health nurse may coordinate and collaborate with the discharge planner and the speech and physical therapists, the only supervisory responsibility will be with the home care aide.
During an initial home visit to assess the client’s needs, the nurse should inform the client
Show answer and rationale
Correct answer: A. about the client’s rights at the start of care.
The Home Care Bill of Rights expects the nurse to obtain informed consent at the start of care, to detail what can be expected from the home care services, and to explain the rights of the client under those services, including the option for advanced medical directives.
The daughter of a client asks the nurse how her mother can become a hospice client. Which of the following is the appropriate response by the nurse?
Show answer and rationale
Correct answer: B. "Anyone can make a hospice referral."
Hospice is a palliative program of coordinated care designed to deliver care to terminally ill clients and their families. Hospice relieves pain and other clinical manifestations without the intention of curing the client. Anyone can refer clients to hospice.
The nurse assesses a hospice client to be unresponsive and incontinent, with limbs that are cool and mottling, and with a blood pressure of 80/48. The nurse evaluates this client as which of the following?
Show answer and rationale
Correct answer: D. Moribund
Although drug overdose may produce some of the clinical manifestations, a client who is moribund, or nearing death, will exhibit cool mottled limbs, be unresponsive and incontinent, and have a low blood pressure.
When preparing for stabilization of a client with end-stage breast cancer who develops a gastrointestinal bleed, it would be essential for the nurse to explain which of the following?
Show answer and rationale
Correct answer: C. Hospitalization for stabilization paid by hospice
Medicare hospice will pay for the hospitalization to stabilize the client’s clinical manifestations for respite, long-term, and short-term care.
A nurse in the pediatric infectious disease unit should give which of the following information about hospice to the family of a child with acquired immunodeficiency syndrome (AIDS)?
Show answer and rationale
Correct answer: B. Hospice provides an interdisciplinary team to support families
Medicare is the only insurance that guarantees medication payment. Medicare does not cover children. A decision to choose hospice care means that the family and caregivers switch from trying to cure to intensive caring, which includes control of the clinical manifestations. Trying to improve the family’s quality of life becomes the goal.
After receiving a terminal diagnosis of congestive heart failure, a client is hostile to family members and hospice staff. The family is very upset by this and asks the nurse why the client is so hostile. The most appropriate response by the nurse is which of the following?
Show answer and rationale
Correct answer: D. "This is a temporary stage, as the client prepares for an imminent death."
Hostility can be a reaction to the realization that one will soon die. The period is usually a short one, as the person generally adjusts to the facts and moves on to completing life’s cycle.
The hospice team has not been able to relieve the client’s pain after repeated tries. One caregiver expresses concern to another caregiver that the pain is not real. The nurse tells the caregiver that pain is
Show answer and rationale
Correct answer: B. an unpleasant sensory and emotional experience arising from tissue damage.
Pain is defined as an unpleasant sensory and emotional experience arising from tissue damage.
A student nurse caring for a hospice client who is moribund and has not had a bowel movement for 5 days asks the nurse about giving the client an enema. Which of the following is the priority response by the nurse?
Show answer and rationale
Correct answer: D. "The body is slowing down and constipation is expected."
The body slows down just before death and constipation is a common condition. Giving an enema or a stool softener would stress the body further. The caregiver can be directed to care in other ways that meet the client’s needs during the last few hours before death.
The nurse should prepare to administer which of the following drugs to a hospice client experiencing mild pain?
Show answer and rationale
Correct answer: C. Codeine
Codeine is the drug commonly given to ease the mild discomfort of a hospice client. Morphine, meperidine (Demerol), and hydromorphone (Dilaudid) are drugs used to treat moderate to severe pain.
Which of the following drugs would be most appropriate for the nurse to administer to a client with end-stage carcinoma who has a recent diagnosis of uncontrollable pain?
Show answer and rationale
Correct answer: D. Morphine
Morphine is appropriate for severe pain. Fentanyl is administered after a client has been on morphine sulfate for an extended time period.
Which of the following clients should the nurse refer to a hospice program?
Show answer and rationale
Correct answer: B. A client who has terminal ovarian cancer
Although diagnoses of breast and pancreatic cancers and a client who is to have a bone marrow transplant all carry uncertain courses of treatment and prognoses, the client must already be determined to be terminal before a referral to hospice can be made.
The outpatient care nurse is discussing postoperative dismissal teaching with an AsianAmerican client. During the discussion, the client looks at the floor, smiles at times, and nods his head. The nurse interprets this nonverbal behavior as a(n)
Show answer and rationale
Correct answer: B. reflection of cultural values.
In the Asian-American culture, eye contact with authority figures is avoided. Head nodding does not necessarily reflect agreement. Direct eye contact is frequently viewed as rude. The Asian-American culture typically avoids confrontation. The word "no" is avoided because it would show disrespect.
The nurse in the emergency room is evaluating a head laceration on an 8-year-old AsianAmerican client. Prior to the physical assessment, the nurse should
Show answer and rationale
Correct answer: A. ask for permission to examine the head.
In the Asian-American culture, the head is considered sacred. Touching the head is seen as disrespectful. Permission must be sought to touch the client. The parents should remain with the child to offer comfort and support.
The admission nurse is gathering family information on an Asian-American client. The client mentions the term "clan." The nurse understands this term to mean
Show answer and rationale
Correct answer: D. a recognized group of families with the same last name and line of ancestors.
In the Asian-American culture, a clan is a family structure that includes a group of individuals considered ancestors and who have the same last name.
The nursing instructor is describing the Chinese-American philosophy of yin and yang to a group of nursing students. The instructor describes how foods are classified using this belief system. Which of the following statements should the nursing instructor include that correctly describes the yin and yang food correlation?
Show answer and rationale
Correct answer: D. Cold foods are consumed when a hot illness is present
In the Chinese-American culture, foods are classified as hot or cold and are transformed into yin and yang energy when metabolized by the body. Yin and yang represent a balance between positive and negative forces. Yin foods are cold and yang foods are hot. Cold foods are eaten when a hot illness is present. Hot foods are eaten when a cold illness is present.
The nurse in the urgent care center is assessing an Asian-American adolescent with complaints of a sore throat. When auscultating lung sounds, the nurse notices round bluish marks along each side of the client’s back. The nurse reports this as which of the following?
Show answer and rationale
Correct answer: D. The practice of cupping
In the Asian-American culture, cupping involves applying a glass over the skin to create a suction that causes the skin to swell and turn bluish. This practice is believed to let the unhealthy air currents out of the body. If an allergy to a medication existed, the rash typically would be located in more areas than just the back. Further investigation and discussion would be necessary before abuse could be suspected.
During a care conference involving the nurse, physician, social worker, Asian-American client, and Asian-American family members, some suggestions for further care are being discussed. The client is sitting in a chair at the edge of the room. The client looks only at the family and does not speak during the conference. The nurse assesses the client’s behavior as
Show answer and rationale
Correct answer: B. a sign of respect for members of the health care team.
The Asian-American culture is typically viewed as quiet, polite, and avoiding direct eye contact. Silence is valued and maintaining a distance is respected. Nonverbal communication is very important.
The nurse is reviewing follow-up instructions with an African-American client. The nurse notices that the client has missed two follow-up appointments in the last week. The client states "something else came up." The nurse interprets this as
Show answer and rationale
Correct answer: D. a cultural value of a flexible time frame.
A characteristic of African-American culture is the concept of time as flexible. The present takes precedent over the future. Members of the cultural group avoid rigidly scheduled appointments.
An African-American client with hypertension is attending a class on ways to take control of hypertension. The nurse explains dietary measures that can be used to help control blood pressure. Which of the following indicates the client has understood the material presented?
Show answer and rationale
Correct answer: A. "I love fried chicken, but will choose broiled skinless chicken as my entr�e."
In the African-American culture, clients typically enjoy fried, fatty foods and slow-cook foods in added fat. The client has made an appropriate alteration to this food choice by choosing broiled skinless chicken over fried chicken. Salt and alcohol should be avoided. Encouraging fresh fruits and vegetables is also appropriate.
An older adult African-American client has just received a diagnosis of prostate cancer. During a discussion with the family and nurse, the client states, "This is all in God’s hands now; there’s not much more I can do." The nurse interprets this statement as the client
Show answer and rationale
Correct answer: B. expressing a cultural belief in the connectedness of God, health, and illness.
In the African-American culture, there is a strong belief in God and the view that God, health, and illness are interconnected.
The nurse is caring for an African-American client who recently had a hysterectomy. The client requests certain herbs from the dietician to be included with meals. When the meals arrive, the client and the faith healer perform a ritual over the herbs. The nurse assesses this as a(n)
Show answer and rationale
Correct answer: A. common practice to combine herbs, faith healing, and Western medicine.
It is common in the African-American culture to combine Western medicine with other traditions. An herbalist or folk healer may be consulted before an individual seeks traditional medicine. Certainly the patient has a right to request herbs and a faith healer. This activity would not warrant the charge nurse being notified.
The nurse in the diagnostic imaging center is preparing an African-American client with a history of headaches for a computerized tomography (CT) scan. Which of the following questions should the nurse avoid asking during the initial assessment?
Show answer and rationale
Correct answer: D. "Do you have a close relationship with your family?"
In the African-American culture, it is considered intrusive to ask personal questions during the initial assessment. Asking a client about having vision changes, shortness of breath, or headaches is physiologically based; these questions take priority during the admission process.
The nurse is involved in discharge planning for an older Hispanic-American client with a terminal illness. The nurse offers services, such as Meals on Wheels, nursing care, and hospice. The client’s family insists on providing all the care. The nurse identifies this situation as a(n)
Show answer and rationale
Correct answer: B. common practice, as it is often seen as a privilege when family members care for older adults.
In the Hispanic-American culture, older adults are respected and honored. Extended families typically live together and provide care as necessary. This is seen as a privilege, not an obligation. Family members encourage involvement of the extended family.
A home health nurse is visiting a HispanicAmerican client who does not speak English. A translator is not available at the time of the visit. The best approach for the nurse to overcome the language barrier is to
Show answer and rationale
Correct answer: C. use simple words, gestures, and pictures.
If a translator is not present with a client who does not speak English, communication will take more time. The nurse must be creative and patient. Using simple words, gestures, and pictures may prove helpful. Written medical terms will not be effective if the client doesn’t understand English. Discussion of one issue at a time does not overcome the language barrier. Rescheduling home visits is not generally acceptable.
A Hispanic-American client arrived at the emergency room complaining of severe stomach pains and cramps. Upon evaluation, the client described to the nurse a home remedy that included massage, prayer, rubbing, and gently pinching the spine. The nurse interpreted this behavior as a(n)
Show answer and rationale
Correct answer: C. example of traditional folk remedies accepted by the Hispanic-American culture.
Folk remedies are widely accepted practices in the Hispanic-American culture. At times, a combination of folk remedies and Western medicine is utilized. Many Hispanic-American clients will not discuss folk remedies with the physician.
The nurse informs another nurse that which of the following statements best describes American Indians’ beliefs about health?
Show answer and rationale
Correct answer: D. "The earth gives food, shelter, and medicine to humankind, and all things of the earth belong to human beings and nature."
Traditional American Indian health beliefs reflect a bond between person and nature. Health is believed to reflect harmony with the surrounding environment and family. Traditional beliefs focus on wellness, not illness. The body is divided into two halves that are seen as plus and minus or two energy poles, one positive and one negative.
The nurse is explaining preoperative information to an American Indian client. The nurse observes the client to be quiet, looking at the picture on the wall, and not readily responding to the nurse’s questions. This behavior would indicate the client
Show answer and rationale
Correct answer: A. is listening to the nurse.
Typical nonverbal behavior of American Indians is quiet listening. Silence is respected and eye contact is considered disrespectful. Communication style is often slow with a low tone of voice and reflection between statements.
The nurse admitting an American Indian client is working on the admission forms. The nurse has asked the client to speak louder and to repeat several comments. The client gets frustrated and won’t continue the interview. Which of the following best describes this interaction?
Show answer and rationale
Correct answer: B. The nurse was unaware of acceptable forms of communication with Indian clients
During an interview, asking an American Indian to speak louder and repeat responses is seen as rude and disrespectful.
A nurse teaching a class on the characteristics of an Arab-American family unit uses the term "patrilineal." The nurse should include which of the following statements to best describe patrilineal?
Show answer and rationale
Correct answer: A. A family group consisting of family members on the father’s side
Patrilineal descent is typical of Arab-American families and means a family group consisting of family members on the father’s side.
The nurse is teaching a class on the cultural aspects of the Arab-American client. Which of the following should the nurse include in this class?
Show answer and rationale
Correct answer: D. The majority of Arabs immigrating to the United States are Muslims
The majority of Arab Americans immigrating to the United States are Muslims. Family members, not friends, are the strongest social unit. Following Islam is the pillar of the ArabAmerican lifestyle. Meals are often consumed very quickly and in silence.
An Arab-American client is referred for continuing care related to dizziness and vision changes. The nurse understands that an Arab-American client would prefer which of the following therapies as a treatment of the condition?
Show answer and rationale
Correct answer: C. Computerized tomography (CT) scan of the head
Generally, Arab-American clients prefer highly technical, even invasive, procedures over noninvasive treatment modalities.
A nurse caring for an Arab-American client is assessing the client’s pain following angiography. The client is lying in bed, eyes tightly closed, and continually asks for more pain medication. The client states, "I asked for pain medication right away and I need it now!" Which of the following nursing actions would be most appropriate at this time?
Show answer and rationale
Correct answer: B. Check to see when the pain medication was last given
It is typical of the Arab-American culture that immediate pain relief is expected and may be persistently requested. Trying to obtain more information or explaining that the nurse was unaware of the discomfort is not appropriate at this time. Assisting another client should be delegated to another staff member.
Which of the following should the nurse include in a class on the health belief system associated with clients of the Russian-American culture?
Show answer and rationale
Correct answer: D. A belief that man has little control over nature
Russian-American cultural belief regarding health is very much the idea that one has little or no control over health and illness. Nature, environment, God’s will, and eating right have no part in the belief system.
A nurse educator is working with staff on cultural diversity issues related to nonverbal communication. The educator explains to another nurse that appropriate nonverbal communication in the Russian-American culture includes which of the following?
Show answer and rationale
Correct answer: C. Nodding is a gesture of approval
Direct eye contact is used and appreciated in the Russian-American culture. Eye contact indicates trustworthiness and honesty. Touch and handshaking are used for formal greetings. Nodding is a gesture of approval.
A care conference is scheduled to discuss the prognosis of a terminally ill Russian-American client. The family members insist that the client not be told the diagnosis. The nurse interprets this behavior as
Show answer and rationale
Correct answer: A. a typical response in Russian-American cultural tradition to dealing with terminal illness.
In the case of a terminal illness, a common Russian-American cultural practice is to only disclose the medical condition to nearest relatives. It is believed the client will do better if the client continues to have hope for recovery.
A family has recently moved to a new metropolitan area and is looking for a health care delivery system that will serve the needs of all family members, including a father who is an older adult and recently had a stroke and is in need of rehabilitative services. The nurse informs the family that which of the following agencies would be the best health care choice?
Show answer and rationale
Correct answer: A. A university medical center and outpatient services
Tertiary health care services include restorative and rehabilitative services for clients of all ages. A university medical center with outpatient services is best equipped to deliver care across the continuum for this family. A home health care service, suburban community, and health promotion services for the entire family are limited to a specific level of care.
A family selected population-based health care practice of America. The nurse manager teaching this family about the health care services available would include which of the following statements?
Show answer and rationale
Correct answer: C. "We have an asthma clinic specifically for clients of all ages."
Population-based health care practice is the development, provision, and evaluation of multidisciplinary health care services to population groups experiencing an increased risk in partnership with consumers of health care and the community, in order to improve the health of the community and its diverse population groups. Population-based care is a managed care approach for a specific group of clients, not just individuals. The goal of care in a population-based system is to maintain and promote wellness, not restorative care. Specialty care and palliative care can be a part of the services, but may not be the priority; referral to a larger system is not necessary.
Based on an understanding of evidence-based client care, the nurse manager should include which of the following instructions for the staff on how to address the home-care needs of a group of clients who have had knee replacements?
Show answer and rationale
Correct answer: B. "Dietary instructions at home are based on common standards of practice and the most recent research for promoting healing."
Evidenced-based practice is a combination of knowledge and expertise in clinical practice, as well as the most recent research findings, used with each specific client. Although clients usually understand the exercise plan needed to strengthen overall muscle and joints, anxiety can be minimized with teaching and practice dealing with steps. Knee replacement care is complex, but the age of the client is not relevant. Dietary instructions, such as increase in protein, are important for healing following a knee replacement.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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