the nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult
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Nursing Elites

NCLEX-RN

NCLEX RN Predictor Exam

1. During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?

Correct answer: B

Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.

2. A client is diagnosed with ariboflavinosis. Which of the following foods should the nurse serve this client?

Correct answer: B

Rationale: Ariboflavinosis is a vitamin B-2 deficiency. Symptoms may include cracks around the mouth, inflammation of the tongue, or light sensitivity. Foods rich in vitamin B-2, like milk, liver, green vegetables, or whole grains, are recommended. Citrus fruits (choice A) are good sources of vitamin C, not B-2. Fish (choice C) is a source of protein and omega-3 fatty acids but not a significant source of vitamin B-2. Potatoes (choice D) are a source of carbohydrates but do not provide high levels of vitamin B-2.

3. A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?

Correct answer: A

Rationale: To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.

4. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?

Correct answer: D

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

5. When assisting a client with shampooing his hair while he is still in bed, a nurse raises the bed to approximately the level of her waist. What is the rationale for this action?

Correct answer: C

Rationale: Raising the bed to the level of the nurse's waist while assisting a client with shampooing in bed is done to reduce strain on the nurse's back. This adjustment ensures that the nurse can work comfortably without excessive bending or stooping, thus preventing back injuries. Choices A, B, and D are incorrect. While preventing shampoo from getting into the client's eyes, allowing excess water to run off the bed, and preventing hair tangles are important considerations, the primary rationale for raising the bed is to prioritize the nurse's ergonomic safety and prevent musculoskeletal strain.

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