NCLEX RN Test Bank with Rationales
Question 1 of 5.
The nurse provides home care instructions to a client who is taking lithium carbonate. Which statement by the client indicates a need for further teaching?
A. I need to take the lithium with meals.
B. My blood levels must be monitored very closely.
C. I need to decrease my salt and fluid intake while taking the lithium.
D. I need to withhold the medication if I have excessive diarrhea or vomiting.
Explanation: A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention and could lead to toxicity. Lithium is irritating to the gastric mucosa; therefore, lithium should be taken with meals. Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely: more frequently at first and then once every several months after that. The client should be instructed to withhold the medication if excessive diarrhea, vomiting, or diaphoresis occurs, and inform the primary health care provider if any of these problems arise.
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 .