NCLEX-PN Test #13 2 Flashcards

The PN is assigned to four clients. Using Maslow's hierarchy, which client should be assessed first?

Answer: A client post-op who just arrived to the floor with SpO₂ of 89%

Using Maslow's hierarchy, physiological needs take priority over all others. SpO₂ of 89% represents inadequate oxygenation — the most basic physiological need. This client must be assessed first as hypoxia can cause rapid deterioration. The other clients have needs that are important but not immediately life-threatening.

A client asks the PN a question about surgery that goes beyond the scope of nursing practice. What is the most appropriate response?

Answer: Acknowledge the question and communicate it to the surgeon for a proper response

When a client's question exceeds the nurse's scope or expertise, the appropriate action is to acknowledge the question, avoid guessing or providing potentially incorrect information, and ensure the question is relayed to the appropriate provider (surgeon, physician) who can give an accurate answer. This protects the client and maintains professional boundaries.

A client with end-stage cancer tells the nurse, "I just want to go home and die peacefully." How should the nurse respond?

Answer: "I understand. Let's talk about your wishes and what we can do to make that happen."

The therapeutic response respects the client's autonomy and right to make decisions about end-of-life care. Acknowledging the wish without judgment and exploring options (palliative care, hospice, advance directives) is the appropriate nursing approach. Redirecting to more treatment dismisses the client's expressed wishes and is not therapeutic.

The PN receives a telephone report about a client being transferred from the ICU. Using SBAR format, what information is communicated under "Situation"?

Answer: Current vital signs, reason for transfer, and immediate needs

SBAR structured communication: Situation = what is happening now (client name, location, reason for transfer, current status, and immediate needs). Background = medical history and relevant context. Assessment = clinical judgment about the problem. Recommendation = what action is needed. Clear SBAR communication prevents handoff errors.

A client with chronic obstructive pulmonary disease (COPD) has an order for morphine 2 mg IV for pain. The nurse is aware of the client's condition but notes the pain is moderate-severe (7/10). What is the most appropriate action?

Answer: Administer the morphine as ordered, monitor respiratory rate and SpO₂ closely, and have naloxone available

Opioids are not absolutely contraindicated in COPD. Undertreated pain also impairs respiratory effort by limiting deep breathing. The nurse should administer the morphine as ordered while closely monitoring respiratory rate (hold if < 12/min), SpO₂, and level of consciousness. Naloxone should be readily available. The benefit-risk ratio is acceptable in this scenario.

The nurse is caring for a confused elderly client who is attempting to remove an IV line. Which intervention is most appropriate and least restrictive?

Answer: Place a loose long-sleeved garment over the IV site and engage the client in a meaningful activity

The least-restrictive intervention principle requires trying non-restraint alternatives first. Covering the IV with a long sleeve reduces visibility (out of sight, out of mind) while an activity redirects the client. Restraints are a last resort and can worsen agitation, cause injury, and lead to deconditioning. Document all alternatives tried before restraint use.