the nurse is giving discharge teaching to a client seven 7 days post myocardial infarction he asks the nurse why he must wait six 6 weeks before havin
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Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. The client is receiving discharge teaching seven (7) days post myocardial infarction and inquires why he must wait six (6) weeks before engaging in sexual intercourse. What is the best response by the nurse to this question?

Correct answer: B

Rationale: Following a myocardial infarction, there is a risk of cardiac rupture at the site of the infarction for approximately six (6) weeks until scar tissue forms. The advice to wait until the client can climb two flights of stairs without issues is common among healthcare providers as it indicates an adequate level of physical exertion tolerance and suggests a lower risk of complications during sexual activity. Choice A is not specific to the recovery timeline related to sexual activity post-myocardial infarction. Choice C is inappropriate as alcohol consumption should not be recommended before sexual activity. Choice D, though promoting an active lifestyle, does not directly address the safety concerns related to sexual intercourse post-myocardial infarction.

2. A client is refusing to undergo any more treatments in the hospital and wants to leave against medical advice. When the nurse requests the client to sign an AMA order, the client refuses and leaves. What is the next action of the nurse?

Correct answer: D

Rationale: The nurse cannot force the client to stay in the hospital to receive treatment or to sign an AMA order. It is essential to respect the client's autonomy and decision-making capacity. While involving security or pressuring the client through the physician or spouse may seem like options, they are not appropriate in this situation. The nurse should allow the client to leave if they are competent to make that decision, document the refusal in the client's chart to ensure all actions are appropriately documented, and follow institutional policies for patients leaving against medical advice.

3. What is a key principle of patient teaching that must take place to ensure patient safety?

Correct answer: C

Rationale: A key principle of patient teaching that ensures patient safety is the confirmation of understanding. To ensure patient safety, it is crucial to confirm that the patient comprehends the information provided. This confirmation can be achieved by having the patient repeat back the information or demonstrate understanding through return demonstration. Documenting the patient's understanding is essential to track the effectiveness of the teaching session and ensure that the patient is equipped with the necessary knowledge for their safety. Family members being present or having multiple staff members provide teaching may be beneficial in certain situations, but the primary focus should be on confirming the patient's understanding to enhance safety and promote effective learning.

4. The client with multiple sclerosis is being educated by the nurse on exercises and physical activities. Which statement by the client indicates a need for further teaching?

Correct answer: B

Rationale: The correct answer is, "I should exercise until I am exhausted."? This statement indicates a need for further teaching because patients with multiple sclerosis should avoid exercising to the point of exhaustion or fatigue. Strenuous physical activity can increase body temperature and potentially worsen symptoms in individuals with multiple sclerosis. Choice A is correct because lifting weights and resistance training can be appropriate exercises for patients with multiple sclerosis. Choice C is valid because aerobic exercises can also be beneficial. Choice D is accurate as proper stretching before starting an exercise routine is essential for preventing injuries.

5. Which technological advance is MOST likely to place you at risk for HIPAA violations?

Correct answer: A

Rationale: The correct answer is Social media. Social media platforms such as Facebook can significantly put you at risk for HIPAA violations. It is crucial to never share any patient-related information or comments on social media websites, as this breaches patient confidentiality and violates HIPAA regulations. Choices B, C, and D are less likely to directly lead to HIPAA violations. Word processing programs and spreadsheets are commonly used for documentation and data organization, focusing more on internal operations and not on external sharing of sensitive information that can compromise patient confidentiality. Cloud storage services (Clouds and SOEs) are designed for secure data storage and sharing within regulated environments, and HIPAA compliance can be maintained if used appropriately. However, social media's open and unsecured nature makes it a higher risk for HIPAA violations compared to the other technological advances mentioned.

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