nursing care plans contain which of the following
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Prep

1. Nursing care plans contain which of the following?

Correct answer: A

Rationale: Nursing care plans are legal documents that contain nursing diagnoses, such as an "Alteration of respiratory function". They also contain patient goals and nursing interventions.

2. Which of the following is NOT an acceptable abbreviation?

Correct answer: A

Rationale: The correct answer is A: D/C. D/C is not an acceptable abbreviation as it can be easily confused with both 'discharge' and 'discontinue.' The abbreviations 'tid' (three times a day), 'bid' (twice a day), and 'qid' (four times a day) are commonly used in medical contexts to indicate dosing frequencies and are widely accepted in healthcare settings.

3. A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?

Correct answer: C

Rationale: The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams. Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.

4. During which part of the client interview would it be best for the nurse to ask, 'What's the weather forecast for today?'

Correct answer: A

Rationale: Asking about the weather initiates the social or introductory phase of the interview, allowing the nurse to establish rapport with the client at the beginning. This question can help assess the client's mental status and set a friendly tone. In the body phase, the client responds to the nurse's inquiries, while during the closing phase, either the nurse or the client concludes the interview. Therefore, the best time to ask about the weather forecast is during the introduction phase to facilitate a positive start to the interaction.

5. The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?

Correct answer: A

Rationale: In this scenario, the nurse is cautious about potential diagnostic errors due to incomplete data. When a client withholds information, it can lead to incomplete data, which may result in inaccurate nursing diagnoses and care planning. Therefore, the nurse's primary concern is collecting accurate data to make informed clinical decisions. Choices B, C, and D are not relevant to the situation described. Generalizing from experience, identifying with the client, and lack of clinical experience do not directly address the issue of incomplete data impacting the diagnostic process.

Similar Questions

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?
Efforts by healthcare facilities to reduce the incidence of hospital-acquired infections (HAIs) include an awareness of which of the following?
What is the primary route of transmission of MRSA?
A nurse is completing an incident report about a medication error that she made when she accidentally administered too much insulin to a diabetic client. All of the following are components of this documentation EXCEPT:

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses