NR-222 Health and Wellness - Set 3 - Part 1

Correct Answer: Take action on the highest priority

Taking action means carrying out the intervention that addresses the top priority, in the right manner and sequence. Delivering the session is the doing step, and it corresponds to implementation in the nursing process. Option a is incorrect because linking cues happened earlier, when the nurse decided the language barrier and the family smoking norms explained the gap. That reasoning shaped this session but is not what she is doing now. Option b is incorrect because the stem says the options were already listed. Deciding what could be done and actually doing the chosen one are two separate steps in this model. Option d is incorrect because nothing has been compared yet. Evaluation arrives after the teaching, when the nurse asks him to explain the material back and watches whether his smoking behavior shifts.

Correct Answer: Do not eat or drink after midnight.

Effective communication is simple, brief, and direct, and medical shorthand fails when the client cannot translate it. Plain wording carries the same instruction without asking the client to decode abbreviations. Option a is incorrect because NPO is staff shorthand that most clients have never heard. A client who nods politely at an unfamiliar abbreviation may still eat breakfast and lose his surgical slot. Option b is incorrect because hold and PO intake are both clinical terms borrowed from charting. Words used among nurses do not automatically mean anything to the person receiving the instruction. Option c is incorrect because citing a protocol explains the rule to a colleague rather than telling this man what to do. It also omits the time, which is the part he must remember.

Correct Answer: The comparison with usual practice

Her question names the population, the intervention, the outcome, and the time frame, but never says what the new approach is being measured against. Without a comparison it is a topic rather than a searchable question. Option b is incorrect because adult smokers seen in a primary care clinic are described clearly enough to search on. Age group, behavior, and setting are all specified in the draft as written. Option c is incorrect because setting a quit date is countable, which is exactly what an outcome must be. A vague goal such as improving health would have failed this test, but hers does not. Option d is incorrect because the draft already bounds the question at four weeks. That element is optional in many formulations anyway, and including it here helps limit which studies she needs to read.

Correct Answer: The intimate zone used for hands on care

Bathing places the nurse within arm's length of the client, inside the intimate zone. Because entering it unannounced provokes anxiety, the nurse explains what is about to happen and obtains permission first. Option a is incorrect because the personal zone covers roughly the arm's length to four feet range used for taking a history or teaching. No one can wash a client from that distance. Option b is incorrect because four to twelve feet is where report, visitors, and small group teaching happen. Direct physical care cannot be delivered across a room, so this zone does not apply. Option d is incorrect because twelve feet or more is lecture and community presentation distance. Assigning bedside hygiene to that zone would put the nurse outside the room while providing care.

Correct Answer: Risk for falls related to sedating medication

A risk diagnosis has two parts, the label and the risk factors, and carries no evidence clause because the problem has not happened yet. Sedating medication is a genuine risk factor here. Option a is incorrect because attaching evidence to a risk statement contradicts itself. If findings already prove the problem exists, the client no longer has a risk, and the diagnosis should be written as an actual one. Option b is incorrect because the problem and the cause have traded places. Dizziness is a manifestation rather than the response being named, and age alone is not something nursing care can change. Option c is incorrect because it describes what the nurse plans to do. Teaching is an intervention, and slotting an intervention into the problem position leaves the client's actual response unnamed.

Correct Answer: Pre-interaction, before any contact occurs

The pre-interaction phase begins when the nurse starts preparing and ends before any contact. Reviewing the record and examining one's own feelings, fears, and biases are the defining tasks of this phase. Option a is incorrect because orientation starts at the first meeting, when the nurse introduces herself and explains her role. She has not yet walked through the door in this scenario. Option b is incorrect because the working phase requires a partnership that is already built, with mutual goals under way. Nothing collaborative can happen before the two people have even met. Option d is incorrect because termination closes a relationship that has run its course, through summarizing and evaluating outcomes. Reviewing a chart at the start is preparation, not an ending.

Correct Answer: Teaching the pursed lip breathing technique

Patient teaching is nurse initiated and needs no order, which places it among the independent interventions. Anything carried out on a provider's prescription is a dependent intervention instead. Option b is incorrect because the medication exists only because a provider prescribed it. The nurse still checks the drug and the client's status, though the authority to give it comes from the order. Option c is incorrect because intravenous fluids require a prescription that specifies the solution and the rate. A nurse who hung them without one would be practicing outside her legal scope. Option d is incorrect because oxygen is a drug, and its flow is set by prescription. Adjusting it on nursing judgment alone is permitted only under an emergency protocol written in advance.

Correct Answer: Arrange a qualified interpreter at no charge

Low health literacy combined with limited English makes the barrier much larger, and the client is entitled to a trained interpreter at no cost. Nothing else taught today will land without one. Option a is incorrect because relatives edit, soften, and omit, and a husband has his own stake in what gets said about the birth. Family members are not acceptable substitutes for trained interpreters. Option b is incorrect because material she cannot read teaches nothing. Written resources belong in the languages commonly spoken by the population served, and they supplement a spoken session rather than replacing it. Option c is incorrect because simplifying English does not bridge a language gap, and nodding often signals respect rather than comprehension. A frightened client will agree with sentences she has not understood.

Correct Answer: The feedback that closes the loop

Feedback is the return message showing whether the content was received as intended. Without asking the client to demonstrate or restate, the nurse broadcast information and never learned what was actually understood. Option a is incorrect because the message was delivered; the words about the inhaler were spoken. What never happened was any return signal telling the nurse how those words landed. Option b is incorrect because speech and demonstration both functioned as channels during the visit. Switching to a video or a handout would not repair an exchange that ended before verification. Option d is incorrect because the referent, a newly prescribed inhaler, is exactly what prompted the nurse to speak. A stimulus was clearly present; verification of understanding was not.

Correct Answer: You sound frightened, tell me what worries you most.

Naming the feeling and inviting him to continue keeps the focus on his experience and opens the next door. It gives the nurse the information she needs about what he actually fears. Option b is incorrect because promising a good outcome no one can guarantee soothes the nurse rather than the client. He learns that fear is unwelcome and stops raising it. Option c is incorrect because steering toward the wedding moves away from the frightening subject he raised. Changing the topic signals that his real concern does not belong in this conversation. Option d is incorrect because a reflexive saying of that kind treats a unique man as a generic case and can land as cruelty. Canned phrases also reveal that no one is really listening.

Correct Answer: Ask the client to restate the signs

Knowledge is evaluated by having the client put the content into their own words. Teach-back confirms the nurse explained the warning signs clearly and shows exactly which ones the client actually retained. Option a is incorrect because inviting questions produces a polite no from nearly everyone. Clients who understood nothing answer the same way as clients who understood everything, so the nurse learns nothing useful. Option b is incorrect because watching an injection measures a hand skill. Return demonstration is the right tool for psychomotor content, but nothing about drawing up insulin reveals whether the client recognizes a low sugar. Option d is incorrect because handing over a list is more teaching, not evaluation. The sheet may help at home, though it says nothing about what this client absorbed during the session.

Correct Answer: Diagnosis, because cues are being clustered

Grouping cues so a pattern emerges is the analytic work that produces a diagnostic label. The data were already gathered, and the nurse is now deciding what they mean together. Option b is incorrect because collection had finished before this moment. Assessment covers obtaining, validating, and organizing the findings, while the act of assigning meaning to them crosses into the next step. Option c is incorrect because planning starts once the problems are named. Ranking them, writing outcomes, and choosing interventions all come afterward, and none of that has happened yet in this scenario. Option d is incorrect because judging results requires an outcome to judge against. No expected outcome exists at this point in the process, so there is nothing for the nurse to compare.

Correct Answer: Reassess why the testing did not happen

When an outcome is not met, the nurse looks back at the diagnosis and its cause before touching the interventions. Cost, fear, forgetting, and skill gaps each call for a different plan. Option a is incorrect because repeating the lesson assumes the barrier was knowledge. If she cannot afford the test strips, the finest instruction in the clinic will still produce an empty logbook next month. Option b is incorrect because more time helps only when progress is already visible. Nothing at all has happened here, so stretching the deadline simply delays the moment the real obstacle gets identified. Option c is incorrect because labeling a client that way records the nurse's opinion as if it were data. It also shuts down curiosity about the cause, which is the one thing that would change the result.

Correct Answer: The bias is corrupting the pain assessment

Bias distorts how the nurse receives and interprets a client's message, so a genuine report gets decoded as manipulation. Uncollected or misread pain data makes this a safety problem, not only a matter of courtesy. Option a is incorrect because staff discomfort is the smallest part of the harm here. A client is waiting for pain relief while his report is being discounted before anyone examines him. Option c is incorrect because worrying about a complaint frames the issue as reputation management. The charge nurse's obligation runs to the accuracy of the assessment and the client's untreated symptom. Option d is incorrect because spread of the remark is a secondary worry. What needs correcting immediately is the stereotype that has already filtered this nurse's interpretation of what the client said.

Correct Answer: Reteach using a picture based schedule

When teach-back fails, the plan is revised rather than repeated. Changing the words, the format, or the modality is the nurse's next move, since the explanation, not the client, is what fell short. Option a is incorrect because the same content at a slower pace has already failed twice. Volume and speed are not the variables that changed anything, and a third pass wastes the client's remaining attention. Option b is incorrect because that entry blames the learner for a teaching failure. It also stops the process cold, when the nurse has several untried formats and no evidence that this client is incapable. Option d is incorrect because moving the task to a spouse abandons the client's own understanding. She will be taking these pills herself, and a relative's grasp of the schedule does not travel into her kitchen.

Correct Answer: You think you are dying, tell me more about that.

Restating what he said and inviting him to continue keeps the hardest subject open. A client who raises dying needs to hear that the topic is allowed, not that it will be handled by someone else. Option b is incorrect because turning to the meal tray is the textbook example of changing the subject. He hears that his fear made the nurse uncomfortable and learns not to mention it again. Option c is incorrect because handing the question to the provider postpones it by hours and leaves him alone with it now. The nurse can explore what he understands without disclosing a prognosis. Option d is incorrect because praising his progress contradicts what he is telling her and reads as a polite denial. Optimism offered in place of listening is one of the most common blocks.

Correct Answer: Allow extra time and avoid completing his words

Expressive aphasia leaves comprehension largely intact, so the client knows what he wants to say and cannot get it out. Giving him time and never finishing his sentences preserves his voice and lowers frustration. Option a is incorrect because supplying his words removes the very thing he is struggling to do. Kindly meant interruption still takes the sentence away from him and communicates impatience. Option c is incorrect because aphasia is not deafness, and volume does not help a language deficit. Raising the voice also carries a tone most adults hear as condescending. Option d is incorrect because relatives cannot report what he wants at this meal, and talking over his bed excludes him from his own care. Intelligence is intact; only the output is damaged.

Correct Answer: This is a hard decision, what matters most to you?

Reflecting the question back keeps the decision where it belongs and helps the client examine his own priorities. The nurse supplies information when asked, but the choice about his knee remains his. Option a is incorrect because that phrase is the clearest marker of advice. It removes his autonomy, implies he cannot weigh the options himself, and hands the nurse responsibility for the outcome. Option b is incorrect because deflecting to the surgeon ends the conversation the client just opened. He asked the nurse because he wanted to think aloud, and the door has now been shut. Option c is incorrect because a statistic about other people is a soft recommendation wearing a fact's clothing. It nudges him toward surgery while telling him nothing about what he values.

Correct Answer: Have the etiology rewritten in physiological terms

Naming staff blame inside a diagnosis puts an accusation in the permanent legal record. The etiology should describe the physiological cause, such as prolonged exposure to moisture, which is also what nursing can treat. Option a is incorrect because the care plan is the wrong instrument for a personnel concern. If care was actually missed, that belongs in an incident report and a conversation, not in the client's plan. Option c is incorrect because accuracy is not the only test a diagnosis has to pass. A statement that hands a plaintiff attorney an admission is legally inadvisable even when every word of it is true. Option d is incorrect because the skin is already broken down. Downgrading an existing problem to a potential one would understate what the client has and would strip away the interventions she currently needs.

Correct Answer: Reading the order back and getting confirmation

Closed loop communication is not complete until the receiver restates the message and the sender confirms it. Reading back drug, dose, route, and frequency before administration is what catches a sound alike error. Option a is incorrect because the timing entry is a charting requirement that follows the event. Recording when an order arrived does nothing to verify that the nurse heard the drug name correctly. Option b is incorrect because a rapid response is precisely the circumstance in which spoken orders are permitted. The restriction exists to keep them out of routine care, and it was not violated here. Option d is incorrect because the signature comes later, within whatever window policy allows. A signature obtained tomorrow cannot prevent the wrong drug from entering a vein tonight.