NCLEX RN Test Bank with Rationales
Question 1 of 5.
The nurse caring for a client immediately following transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. The nurse determines that this may be a result of which potential complication of this surgical procedure?
A. Hyponatremia
B. Hypernatremia
C. Hypochloremia
D. Hyperchloremia
Explanation: The client who suddenly becomes disoriented and confused after TURP could be experiencing early signs of hyponatremia. This may occur because the flushing solution used during the operative procedure is hypotonic. If enough solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. The nurse needs to report these symptoms. The conditions noted in the other options are not complications of the procedure.
Question 2 of 5.
What is the primary goal of multidisciplinary case conferences?
A. To fulfill the nurse's role in terms of collaboration
B. To plan and provide for optimal client outcomes
C. To solve complex multidisciplinary patient care problems
D. To provide educational experiences for experienced nurses
Explanation: The primary goal of multidisciplinary case conferences is to plan and provide for optimal client outcomes by bringing together various professionals to coordinate care and address the client's needs holistically.
Question 3 of 5.
Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
A. SBAR: Symptoms, background, assessment and recommendations
B. ISBAR: Interventions, symptoms, background, assessment and recommendations
C. The Five Ps: The patient, plan, purpose, problems and precautions
D. BATON: Background, assessment, timing, ownership and next plans
Explanation: The Five Ps accurately describes a hand-off system with elements: patient, plan, purpose, problems, and precautions, used to ensure comprehensive communication during shift changes.
Question 4 of 5.
Legal prohibitions against sharing passwords are legally based on:
A. The Security Rule
B. The American Nurses Association's Code of Ethics
C. The American Hospital's Patients' Bill of Rights
D. The Autonomy Rule
Explanation: Legal prohibitions against sharing passwords are based on the Security Rule of HIPAA, which mandates safeguards to protect electronic protected health information.
Question 5 of 5.
Which statement about referrals is accurate?
A. Referrals complement the healthcare teams' abilities to provide optimal care to the client.
B. Referrals simply allow the client to be discharged into the community with the additional care they need.
C. Nurses facilitate referrals to only the resources within the facility.
Explanation: Referrals enhance the healthcare team's ability to provide comprehensive care by connecting clients to specialized services, not limited to discharge or internal resources .
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