Exam 2: NCLEX questions

The graduate nurse is interviewed by the manager of a unit and is told that the manager's leadership style is laissez-faire or one of letting the staff nurses make the decisions about the unit's operations. Which question by the graduate nurse indicates the best understanding of the laissez-faire leadership style? A. "As the manager, do you assume a passive, nondirective approach?" B. "As the manager, do you maintain control and make all decisions?" C. "As the manager, do you facilitate decision making within the group?" D. "As the manager, do you change style according to the needs of the group?"

A. "As the manager, do you assume a passive, nondirective approach?"

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? A. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients. B. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). C. A staff member is assigned to determine the client's needs at home and begin discharge planning. D. Each staff member is assigned a specific task for a group of clients.

A. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? A. Call the nursing supervisor B. Call Security C. Call Police D. Lock the coworker in the medication room until help is obtained

A. Call the nursing supervisor

The nurse is rearranging the client assignments after several discharges and admissions occurred. Which tasks should be assigned to the assistive personnel (AP)? Select all that apply. A. Cleaning a client's dentures B. Ambulating a postoperative client C. Taking 4:00 p.m. vital signs on clients D. Giving medications left by the nurse for the client to take E. Assisting a client with a urinary drainage catheter into a chair F. Obtaining a catheterized urinalysis and taking it to the laboratory

A. Cleaning a client's dentures B. Ambulating a postoperative client C. Taking 4:00 p.m. vital signs on clients E. Assisting a client with a urinary drainage catheter into a chair

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? A. Contact the nursing supervisor B. Administer the dose prescribed C. Hold the medication until the PHCP can be contacted D. Administer the recommended dose until the PHCP can be located

A. Contact the nursing supervisor

Stephanie delegates effectively if she has authority to act, which is best defined as: A. Having a legitimate right to act. B. Having a responsibility to direct others. C. Being accountable to the organization. D. Telling others what to do.

A. Having a legitimate right to act.

The nurse manager is discussing the facility protocol in the event a tornado with staff. Which instructions should the nurse manager include in the discussion? Select all that apply. A. Open doors to client rooms B. Move beds away from windows C. Close window shades and curtains D. Place blankets over clients who are confined to bed E. Relocate ambulatory clients from the hallways back into their rooms

B. Move beds away from windows C. Close window shades and curtains D. Place blankets over clients who are confined to bed

The nurse is responsible for the care of a client who has begun to experience hallucinations more frequently. Which activity in the care of the client can be most appropriately delegated to an assistive personnel (AP)? A. Determining if the client has consistently been medication compliant. B. Providing distraction for the client by engaging the client in a board game. C. Discussing the frequency and duration of the hallucinations with the client. D. Assisting the client in identifying any new stressors he or she may be experiencing.

B. Providing distraction for the client by engaging the client in a board game.

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply. A. Complete and file an occurrence report B. Right-click on the entry and modify it to reflect the correct information C. Document the correct information and end with the nurse's signature and title D. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg E. Document in a nurse's note in the client's record detailing the corrected information

B. Right-click on the entry and modify it to reflect the correct information C. Document the correct information and end with the nurse's signature and title D. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg E. Document in a nurse's note in the client's record detailing the corrected information

The registered nurse (RN) has provided instructions to a licensed practical nurse (LPN) regarding administering enemas to a client scheduled for a barium enema. The RN has instructed the LPN to administer enemas until they are clear. The LPN tells the RN that 3 enemas were administered and that the returns are still not clear. What most appropriate instruction should be given to the LPN? A. Administer 1 more enema B. Stop administering the enemas C. Continue to administer enemas until the solution is clear D. Wait for 1 hour and then continue administering the enemas

B. Stop administering the enemas

The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power? A. "The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors." B. "If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance, which could lead to termination of your employment." C. "Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." D. "You're just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way."

C. "Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care."

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? A. "I will sign as a witness to your signature" B. "You will need to find a witness on your own" C. "I will call the nursing supervisor to seek assistance regarding your request" D. "Whoever is available at the time will signs as a witness for you"

C. "I will call the nursing supervisor to seek assistance regarding your request"

Joey stresses the importance of promoting 'esprit d corps' among the members of the unit. Which of the following remarks by the staff indicates that they understand what he pointed out? A. "We will ensure that all the resources we need are available when needed." B. "In order that we achieve the same results; we must all follow the directives of Julius and not from other managers." C. "Let's work together in harmony; we need to be supportive of one another." D. "We need to put our efforts together in order to raise the bar of excellence in the care we provide to all our patients."

C. "Let's work together in harmony; we need to be supportive of one another."

The nurse is delegating the morning hygiene care of a man to the assistive personnel (AP). In reviewing the assigned tasks, the nurse should instruct the AP to use an electric razor for which client? A. The client with severe pain related to osteoporosis B. The client with hypokalemia related to diuretic therapy C. The client with thrombocytopenia related to chemotherapy D. The client with an elevated white blood cell count related to infection

C. The client with thrombocytopenia related to chemotherapy

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. A. The nurse who never had roseola B. The nurse who never had mumps C. The nurse who never had chickenpox D. The nurse who never had German measles E. The nurse who never received the varicella-zoster vaccine

C. The nurse who never had chickenpox E. The nurse who never received the varicella-zoster vaccine

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. A. The nurse who never had roseola. B. The nurse who never had mumps. C. The nurse who never had chickenpox. D. The nurse who never had German measles. E. The nurse who never received the varicella-zoster vaccine.

C. The nurse who never had chickenpox. E. The nurse who never received the varicella-zoster vaccine.

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? A. "Cushing's syndrome is caused by decreased amounts of parathyroid hormone." B. "Cushing's syndrome is caused by decreased amounts of aldosterone." C. "Cushing's syndrome is caused by excessive amounts of antidiuretic hormone." D. "Cushing's syndrome is caused by excessive amounts of cortisol."

D. "Cushing's syndrome is caused by excessive amounts of cortisol."

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? A. A client who is ambulatory demonstrating steady gait B. A postoperative client who has just received an opioid pain medication C. A client scheduled for physical therapy for the first crutch-walking session D. A client with a white blood cell count of 14,000 mm3(14 x 109/L) and a temperature of 38.4° C

D. A client with a white blood cell count of 14,000 mm3(14 x 109/L) and a temperature of 38.4° C

The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? A. Substance abuse disorder B. Post-traumatic stress disorder C. Hyperlipidemia D. Hypertension

B. Post-traumatic stress disorder

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? A. Call security B. Call the police C. Call the nursing supervisor D. Lock the coworker in the medication room until help is obtained

C. Call the nursing supervisor

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first? A. Blood pressure 154/72 mmHg B. Visual acuity of 20/200 in both eyes C. Complaints of pain associated with numbness and tingling in both feet D. Random blood glucose level of 206 mg/dL (11.47 mmol/L)

C. Complaints of pain associated with numbness and tingling in both feet

The nurse is seeking a leadership style that will empower staff to achieve excellence. Which leadership style should the nurse select to achieve this goal? A. Autocratic B. Democratic C. Laissez-faire D. Situational

B. Democratic

Select the types and stages of conflict that are accurately paired with their description. Select all that apply. A. Frustration: The phase of conflict that is characterized with personal agendas and obstruction. B. Taking action: The phase of conflict that is characterized with individual responses to and feelings about the conflict. C. Conceptualization: The phase of conflict that occurs when contending parties have developed a clear and objective understanding of the nature of the conflict and factors that have led to it. D. Resolution: The type of conflict that can be resolved. E. Avoidance-Avoidance: A stage of conflict that occurs when there are NO alternatives that are acceptable to the contending parties. F. Approach- Approach Conflicts: The type of conflict that occurs when the people involved in the conflict want more than one alternatives or actions that could resolve the conflict. G. Approach-Avoidance Conflicts: The type of conflict that occurs when the people involved in the conflict believe that all of the alternatives are NEITHER completely satisfactory nor completely dissatisfactory.

B. Taking action: The phase of conflict that is characterized with individual responses to and feelings about the conflict. F. Approach- Approach Conflicts: The type of conflict that occurs when the people involved in the conflict want more than one alternatives or actions that could resolve the conflict. G. Approach-Avoidance Conflicts: The type of conflict that occurs when the people involved in the conflict believe that all of the alternatives are NEITHER completely satisfactory nor completely dissatisfactory.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? A. The client fell out of bed. B. The client was found lying on the floor. C. The client became restless and tried to get out of bed. D. The client climbed over the side rails.

B. The client was found lying on the floor.

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which clients as most typically a victim of abuse? A. A man who has moderate hypertension B. A man who has newly diagnosed cataracts C. A woman who has advanced Parkinson's Disease D. A woman who has early diagnosed Lyme Disease

C. A woman who has advanced Parkinson's Disease

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? A. Call for help B Extinguish the fire C. Activate the fire alarm D. Confine the fire by closing the room door

C. Activate the fire alarm

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is a characteristic of the team-based model of nursing practice? A. Each staff member is assigned a specific task for a group of clients. B. A staff member is assigned to determine the client's needs at home and begin discharge planning. C. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). D. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

D. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

The nurse is planning client assignments for the day. Which clients can be safely assigned to assistive personnel (APs)? Select all that apply. A. Client who is receiving chemotherapy and is in isolation. B. Client with anemia who is receiving a second unit of blood and needs assessment of vital signs. C. Client new diagnosed with hyperthyroidism who is in need of teaching regarding medication therapy. D. Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing. E. Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding. F. Client who is newly admitted with shortness of breath, circumoral cyanosis, and a respiratory rate of 30 breaths per minute who requires an admission assessment.

D. Client who is 72 hours postoperative recovering from a total knee replacement and needs assistance with bathing and dressing. E. Client who is 48 hours postoperative recovering from an open reduction and fixation of the right forearm and needs assistance with feeding.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 30 minutes

D. Every 30 minutes

When Henry uses Team Nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients. Which of the following should be a priority? A. Each patient is listed on the worksheet. B. Patients who need the least care. C. Medications and treatments required for all patients. D. Patients who need the most care.

D. Patients who need the most care.

The nurse educator presents an in-service training session on case management to nurses on the clinical unit. During the presentation, the nurse educator clarifies that what is a characteristic of case management? A. Requires that 1 nurse take care of 1 client B. Requires a case manager who plans the care for all clients C. Uses a team approach, but 1 nurse supervises all other employees D. Promotes appropriate use of hospital personnel

D. Promotes appropriate use of hospital personnel

As a manager, Rebecca focuses her energy on both the quality of services rendered to the patients as well as the welfare on the staff of her unit. Which of the following management styles does she adopt? A. Country club management B. Organization man management C. Authority-obedience management D. Team management

D. Team management