Acute Care: Part II
NCLEX- Style Questions
NCLEX- Style Questions
Question 1
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The nurse should implement which of the following interventions to enhance Mrs. Zhang’s privacy and comfort while she is in the surgical ward? Select all that apply.
- Encourage the use of a sleep mask.
- Offer soothing music.
- Advocate for a transfer to a private room if available.
- Close the curtain around her bed when providing care.
- Avoid addressing her needs until she verbalizes discomfort.
- Provide earplugs.
Question 2
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Question 3
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The nurse recognizes that Mrs. Zhang’s family is concerned about her condition in the ICU and wants to know how they can help. Which nursing response should the nurse provide to best support family-centered care?
- The nurse tells the family that ICU visits are disruptive and should be limited.
- The nurse encourages the family to visit, ask questions, and participate in Mrs. Zhang’s care when appropriate.
- The nurse provides minimal updates on Mrs. Zhang, as explaining medical details may overwhelm the family.
- The nurse reassures the family that they will receive all information after Mrs. Zhang is discharged.
Question 4
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Question 5
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The nurse is assessing Mrs. Zhang for manifestations of ICU-related delirium. Which environmental factor(s) contribute most to ICU-related delirium? (Select all that apply
- Allowing family members to visit frequently and interact with the patient.
- Having a consistent day-night lighting schedule in the ICU.
- Bright lighting and frequent sleep disruptions.
- A quiet and dark ICU room with minimal stimulation.
- Mechanical ventilation and the constant beeping of monitors
- Frequent staff interruptions for assessments and procedures.
- Limited human interaction and restricted mobility.
Question 6
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The nurse is working with the interprofessional care team to manage Mrs. Zhang’s post-operative ICU care. Mrs. Zhang is intubated and unable to speak. Her family expresses concerns about her care plan. Which actions by the nurse and the interprofessional team best align with the principles of the Registered Nurses’ Association of Ontario’s (RNAO) Model of Interprofessional Care (2013)? (Select all that apply.)
- The dietitian finalizes Mrs. Zhang’s enteral feeding regimen based on standard ICU protocols.
- The ICU team restricts Mrs. Zhang’s family visits to reduce stress for both the staff and patient, ensuring a quieter healing environment.
- The nurse practitioner communicates with the family once per day to streamline care coordination and avoid conflicting information.
- The ICU nurse and respiratory therapist collaborate to assess ventilator settings before making any changes based on Mrs. Zhang’s respiratory status.
- The social worker arranges a family meeting to provide emotional support and ensure Mrs. Zhang’s family understands her care plan.
- The ICU team invites Mrs. Zhang’s family to participate in decision-making surrounding her plan of care when appropriate.
- The pharmacist independently modifies Mrs. Zhang’s medication regimen to expedite treatment.
- The charge nurse facilitates an interprofessional huddle with all team members, including Mrs. Zhang and her family, to collaborate on her next steps.
