Page 2589 - Saunders Comprehensive Review For NCLEX-RN

to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health: Endocrine
Health Problem: Adult Health: Endocrine: Diabetes mellitus
Priority Concepts: Client Education; Glucose Regulation
Reference: Ignatavicius, Workman, Rebar (2018), pp. 1281, 1310.

875. Answer: 3

Rationale: In the Puerto Rican–American culture, loud crying and other physical
manifestations of grief are considered socially acceptable. Of the options provided,
the correct option is the only one that identifies a culturally sensitive approach on
the part of the nurse. Options 1, 2, and 4 are inappropriate nursing interventions.
Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the
clients of the question, the family members. Use therapeutic nursing interventions,
recalling the characteristics of the culture and the importance of cultural sensitivity.
This will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Culture and Spirituality
Content Area: Foundations of Care: Spirituality, culture, ethnicity
Health Problem: Mental Health: Grief/Loss
Priority Concepts: Culture; Family Dynamics
Reference: Lewis et al. (2017), pp. 25, 30.

876. Answer: 1

Rationale: The priority nursing action is to assess the vital signs. This would
provide information about the amount of blood loss that has occurred and provide a
baseline by which to monitor the progress of treatment. The client may be unable to
provide subjective data until the immediate physical needs are met. Although an
abdominal examination and an assessment of the precipitating events may be
necessary, these actions are not the priority. Insertion of a nasogastric tube is not the
priority and will require a primary health care provider’s prescription; in addition,
the vital signs should be checked before performing this procedure.
Test-Taking Strategy: Note the strategic word, priority, and use the ABCs—
airway, breathing, circulation. This will direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Gastrointestinal: Upper GI disorders
Priority Concepts: Care Coordination; Clinical Judgment
Reference: Lewis et al. (2017), p. 924.

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