NCLEX RN Test Bank with Rationales
Question 1 of 5.
The nurse is transferring a client who is G4 P3 at 25 weeks' gestation with preeclampsia from the obstetrical intensive care unit to the antenatal unit. To safely manage this preeclamptic client, what should be included in the transfer report about this client? Select all that apply.
A. Record of blood pressure trends
B. Record of urine protein
C. Edema observed by health care provider
D. Client use of dietary sodium
E. Fetal position
F. Fetal heart rate pattern
Explanation: For a client with preeclampsia, the transfer report should include blood pressure trends, urine protein levels, edema observations, fetal position, fetal heart rate patterns, and medical/nursing interventions, as these are critical for monitoring maternal and fetal status. Dietary sodium use is less critical unless specifically restricted.
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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