Please Help

i'm practicing for taking (nclex) test but still confused with lots of these questions. i couldn't find right answer to these questions with rationale and am now looking for someone who can help me out and refresh me with these concepts.

an example of an independent nursing intervention is:

a. administrating intravenous fluids for a client diagnosed with nutritional impairment.

b. turning and repositioning a client impaired mobility every 2 hours.

c. ordering a chest x-ray for a client diagnosed with ineffective breathing pattern.

d. reviewing laboratory values and reordering tests for abnormal values.

yes, b, is correct. this is the only intervention we, as nurses, can do w/o an order from the md

which of the following is considered an example of a standing physician's order?

a. a protocol for indwelling urinary catheter care.

b. hemoglobin and hematocrit two days postpartum on all postpartum patients.

c. the procedure for the flush of peripherally inserted central line catheters.

d. skin care protocol for a client who is immobile.

i think b is the answer to this one as well. the other choices seem to be more like hospital policies & procedures/protocols, rather than standing orders.

using aseptic technique, a nurse demonstrate insulin preparation to a client. this is an example of which phase of the nursing process?

a. assessment

b. implementing

c. diagnosing

d. planning

i think the answer here is b. demonstrating a technique to a pt is part of the implementing part of adpie. if it were planning, you would be deciding what supplies you needed, what time of day the pt would best learn, etc.

which of the following would create an opportunity for the nurse to teach a client?

a. medication administration

b. vital sign measurement

c. changing a wound dressing

d. all of the above

i actually think the answer here is d. my rationale would be that med admin is a great time to teach (see question above), and changing a wound dsg is also a great time to teach (assuming the pt will have to continue at home), so by default vital sign measurement would have to be included as a teachable moment. there are lots of pts who have to take their pulse for instance before taking certain cardiac meds (digoxin, etc)

review the following nursing diagnosis, and identify those that are stated correctly or incorrectly:

a. ineffective breathing pattern r/t pneumonia correct or incorrect

b. risk for change in body image r/t cancer correct or incorrect

c. ineffective airway clearance r/t increased secretions correct or incorrect

d. anxiety r/t uncertainty over surgery correct or incorrect

a & b are incorrectly stated because they use a medical dx in the nursing dx, and that is a big no-no.

c & d seem to be correctly stated to me.

hope this helps

I agree with all of the answers the person above me picked!

Thank you very much for helping out and forgive for not replying sooner I had problems with my computer. You guys are great! Thank you for your support!

I did find two more questions that I'm stock with as well just a little bit and I couldn't find a rationale for them can someone please help me:

You determine that your client has not met an expected outcome .What action do you take?

a. Call a meeting of the interdisciplinary team.

b. Ask the client why the goal was not accomplished.

c. Call for a nursing consultation.

d. Review and revise the care plan.

You are to administer an IV medication. Your clinet has total parental nutririon (TPN), lipids, and a minibag of potassium (KCL) supplement infusing through separate IV lines. After preparing the IV medication you enter the client's room and are unsure which IV line to administer the medication. What should you do?

a. call the pharmacy for help.

b. ask a fellow student nurse for an opinion.

c. seek the assistance of the staff nurse assigned to your client.

d. use the IV line that is infusing the TPN.

Can you give reasons to why you picked d and c to your last questions?

D and C make more sense to me reviwing and revising the care plan and seeking for assistance if I was unsure which IV line to administer the medication make more sense to me.

Can anybody else help me out with these two questions PLEASEEEEEEEEEEE!!!!!!!!!!

I believe the correct answers are underlined.

For the first, it's not necessarily a team problem, so you wouldn't need to involve a team. The patient will be included in conversations about the plan and outcomes but you won't just ask them why a goal was not accomplished because they may not have a full understanding of the goal- and it could make them defensive. I would imagine a nursing consultation may be in order, but you couldn't have that meeting either until you at least reviewed the care plan.

For the second, I wouldn't call the pharmacy because that's not a formulation problem, it's an administration problem. And I wouldn't be consulting with fellow nurses in any official capacity. I wouldn't use the TPN line because you don't know the compatibility of the medication and the TPN. I think that some formulations can make some of the TPN precipitate.

Those are just the answers I would pick, and I'm only a first semester student so I'm not sure how helpful that is.

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