Leadership

Staffing needs are determined by which of the following: a. Nurse-patient ratios b. Nurse-shift ratios c. Staff mix ratios d. All of the above

Answer: a. Nurse-patient ratios b. Nurse-shift ratios c. Staff mix ratios Rationale: It is the responsibility of the nurse manager to take into consideration the number of patients, nurses, and staff to determine how many staff are needed to conduct safe nursing care (Monahan, 2010. PG 47)

1. A nurse is caring for a patient from Spain who experienced a hypertensive crisis while on vacation in the United States. The patient knows only a few words of English. What is the most important when planning a teaching session about nutrients that are high in sodium? a. Providing a professional interpreter fluent in Spanish b. Securing written materials in Spanish from the internet c. Using the technique of demonstration when teaching information d. Showing pictures of foods that should be avoided to lower blood pressure

Answer: A Rational: The joint commission requires hospitals to provide professional interpreters or an interpreter service via a phone link so that patients clearly understand their condition, medical treatment, and nursing plan of car. In addition, interpretive services much be provided when engaging a patient in teaching and learning.

A mother brings her child to the emergency department after her husband beat the child. She's afraid to return home. The nurse can refer the mother to several social service agencies. Which agency would be most important? a. Women's shelter b. Welfare bureau c. Children's protective services d. Homeless shelter

Answer: A Rationale: A women's shelter can provide services necessary for both mother and child. The other alternatives may result in separation of the child from the mother and cause further trauma (Munden, Shaeffer, & Williams, 2008).

An RN in caring for a terminally ill patient who says "Sometimes I just want it all to end". The RN should examine the client's medical record for which of the following documents: a. Advance directives b. Power of attorney c. DNR orders d. Living will

Answer: A Rationale: Advance directives specify the client's wishes regarding health care decisions. Reference: Kaplan NCLEX review 2014-2015

Which of the following room assignments is considered unsafe? a. A nurse caring for patient A with chickenpox and patient B with AIDS b. A nurse caring for patient A with a total knee arthoplasty and patient B who is receiving external radiation c. A nurse caring for patient A with appendicitis and patient B with sepsis d. A nurse caring for patient A who is post-op CABG and patient B who is post-op CEA

Answer: A Rationale: An AIDS patient is immunocompromised

A competent RN understands HIPPA when he or she notes the following statements is true: a. The RN must request the client's permission to share medical records with an insurance company b. The RN discusses the client's information over lunch in a hospital cafeteria with a coworker c. The RN keeps a list of patient names at the front desk in clear view so that physicians can efficiently locate patients d. The RN gives information regarding the patient's status over the phone without a password to a concerned friend or family member

Answer: A Rationale: HIPPA act of 1996 provides clients with basic rights pertaining to their medical records and the nurse must abide by those rights Reference: Kaplan NCLEX book 2014-2015

A competent RN knows information technology has advanced in development and use in all aspects of patient care because of the following: a. Information technology improves patient care through comprehensive evaluation of the safety, effectiveness, and cost benefits b. Information technology plays a major role in reducing health care costs c. Information technology assists nurses in delivering care in remote areas d. Information technology helps nurses understand, apply, and disseminate the principles of health care technology

Answer: A Rationale: Information technology does improve patient care through updated safety mechanisms and cost effectiveness. Reference: Kaplan NCLEX book 2014-2015

A 45 year old female weighing 350lbs and left-sided weakness is 12 hours post-op TKA and incontinent. She calls the nurse's station needing a bed change. A tech starts collecting supplies to do a bed bath by herself. What action should the charge nurse take? a. Stop the tech and advise her to request the help of another tech and the patient's primary nurse b. Praise the tech for being on top of things c. Stop the tech and inform her that this patient needs the RN give her a bed bath due to her knowledge of post-op TKA procedures d. Tell the patient that if she can't call before this happens again then the RN is going to insert an indwelling Foley catheter.

Answer: A Rationale: The tech should ask for assistance because conducting the bed change by herself is a safety concern for both the tech and patient.

A patient is being referred to a rehab facility after a total knee arthroplasty. Which of the following documents must be included in the referral? Select all that apply. a. Medical record b. Referral form c. Physician order for transfer d. Care notes

Answer: ABC Rationale: A, B, C all need to be included when a patient is transferred to a new facility. Care notes are not necessary.

6. The nurse educator is discussing fire safety with new employees. List in order of performance the following actions the nurse should teach to ensure the safety of clients and employees in the case of a fire on the unit a. Extinguish b. Rescue c. Confine d. Alert

Answer: BDCE Rationale: RACE is the recognized standard for fire safety in healthcare facilities (Hargrove-Huttel & Colgrove, 2009. PG 33)

Which of the following is appropriate when using an interpreter to communicate with a client and his family? (Select all that apply.) a. Talk to the interpreter about the family while the family is in the room. b. Ask the family one question at a time. c. Look at the interpreter when asking the family questions. d. Use lay terms if possible. e. Do not interrupt the interpreter and the family as they talk.

Answer: BDE Rationale: Asking the family one question at a time, using lay terms, and not interrupting will promote communication between the family and the nurse/interpreter. Talking to the interpreter about the family while the family is in the room and looking at the interpreter instead of the family would hinder communication between the family and the nurse/interpreter. Source: http://www.atitesting.com/ati_next_gen/FocusedReview/data/datacontext/RM%20Fundamentals%207.0%20Chp%2035.pdf

A nurse from an oncology unit is reassigned to an OB unit due to unexpected staffing issues. The oncology nurse feels unprepared to care for OB patients. What would be the best decision for her to make? a. Accept the assignment even though she feels unprepared b. Ask the OB unit nurses to teach her as she goes along during the day c. Refuse the assignment to her manager because she does not feel adequately trained and ask for an alternate assignment d. Ask other oncology staff members their opinions on the assignment before she accepts or refuses

Answer: C Rationale: A nurse has the right to refuse any assignment in which he/she does not feel they have adequate training to correctly care for those patients. Asking for another assignment would show they are still willing to be a team player, just in an area where they feel comfortable working. Reference: Management class lecture/discussion

1. The client is diagnosed with a small abdominal aortic aneurysm. Which statement by the client indicates to BN the client needs more discharge teaching? a. "I should not life more than 5 lbs for 4-6 weeks." b. "I attend a support group to help me quit smoking." c. "I will need to wear a truss at all times after the surgery." d. "If I get a temperature of 101 or higher, I will call my doctor."

Answer: C Rationale: A truss is a kind of surgical appliance used for clients with a hernia. It provides support for the herniated area using a pad and belt arrangement to hold it in the correct position. This client would not be prescribed a truss; therefore, the client needs more discharge teaching. (Hargrove-Huttel & Colgrove, 2014)

1. A charge nurse in a nursing home identifies that the weights of residents assigned to a particular nursing assistant are exactly the same as the week before. The nurse is concerned that the nursing assistant is not weighing residents and is falsifying the weights. What should the nurse do first? a. Confront the nursing assistant responsible for taking the weight b. Report the problem regarding the nursing assistant to the nursing supervisor c. Reweigh the residents assigned to the nursing assistant who had duplicate weights for both weeks. d. Assign the nursing assistant to take the weight of another resident and observe is the weight is actually taken.

Answer: C Rationale: If there is a substantial difference between the weights taken by the nursing assistant and the charge nurse, then there is some evidence to indicate that the nursing assistant has not followed proper procedures. The next step is for the charge nurse to meet with and counsel the nursing assistant according to the policy and procedures of the facility (Nugent & Vitale, 2014, p. 55 & 61)

1. The nurse is providing end-of-life care to the client diagnosed with cardiomyopathy who is in hospice. Which priority assessment intervention should the nurse implement? a. Assess the clients spiritual needs b. Assess the client's financial situation c. Assess the client's support system d. Assess the client's medical diagnosis

Answer: C Rationale: Prioritization, Delegation, & Management of Care for the NCLEX-RN Exam page 13. The client's support system is the priority assessment for the hospice nurse. The client will be cared for in the home and the nurse must know who is available to help the client.

1. A nurse manager is trying to find ways to better manage her time and organize her workload. Which of the following is NOT a way to manage time? a. Setting goals b. Prioritizing c. Taking on the tasks of others that are not being completed, so that they get done on time d. Daily planning

Answer: C Rationale: Setting goals, prioritizing, and daily planning are all steps in managing time. Taking on extra work will increase the workload of the nurse, which will not help manage time. (Sullivan)

2. The charge nursing in a large outpatient clinic notices the staff is arguing and irritable with one another and the atmosphere has been very intense for the past week. Which action should the charge nurse implement? a. Wait for another week to see whether the situation resolves itself b. Write a memo telling all staff members to stop arguing c. Schedule a meeting with the staff to discuss the situation d. Tell the staff to stop arguing or staff will be terminated

Answer: C Rationale: The charge nurse should attempt to determine what is causing the problem and the tense atmosphere directly. The charge nurse could then problem solve, the goal being to have a relaxed atmosphere in which to work. (Client Leadership and Management 2009, pg 128)

1. Which of the following health care team rules is incorrect? a. A physician diagnoses and treats disease b. A physical therapist assists in examining, testing, and treating physically disabled clients c. A respiratory therapist develops devices that help chronically ill or handicapped clients perform activities of daily living d. A nutritionist or dietician assists in planning dietary measures to improve or maintain a client's nutritional status

Answer: C Source: Saunders, 2011

A nurse working in the emergency department of a hospital is interviewing an extremely agitated patient who keeps standing up, pacing, and sitting down. The RN asks the charge nurse what the most appropriate response would be to this patient? a. "Please sit down so that we can discuss your concerns." b. "Your behavior is inappropriate and you have to try to control it." c. "Let's go to a quiet room because your anxiety may be contagious." d. "Come with me for a walk and you can describe what is bothering you."

Answer: D Rationale: "Offering to walk with the patient during the interview allows the patient to expend energy while voicing concerns." Nugent 179&184

The nurse arrives at work and is told to report (float) to the ICU for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? a. Call the hospital lawyer b. Refuse to float to the ICU c. All the nursing supervisor d. Identify tasks that can be performed safely in the ICU

Answer: D Rationale: Floating is an acceptable legal practice used by hospitals to solve understaffing problems. When encountering this situation, the nurse should set priorities and identify potential areas of harm to client (Saunders, 2014).

1. A RN is assigned to the ICU for the day. One of the patients assigned to the RN has stage III (resolution phase) ARDS who is immobile, with an ET (endotracheal tube), has reduced renal output, and receiving NG tube feedings. Which of the following professions is the most important for the nurse to collaborate with for this stage? a. Dietary/nutritional services b. Chaplain c. Occupational Therapy d. Respiratory Therapy

Answer: D Rationale: In the resolution phase, weaning the patient from the vent is of utmost importance. (Source: http://www.ards.org/learnaboutards/whatisards/brochure/)

A patient is newly admitted to your unit with signs and symptoms of that are suggestive of Hepatitis A. What hepatitis A related history should the nurse know to gather? a. Recent travel history. b. History of injected drug use c. Vaccination history d. All of the above

Answer: D Rationale: People are at risk of acquiring Hepatitis A if they have recently traveled, participated in injectable drug use, have not had the hepatitis A vaccine, as well as other risks such as consuming contaminated food and water.

A nursing manger recognizes anxiety in his/her staff member when he/she sees the following: a. Avoiding responsibilities b. Acting impatient toward other staff members c. Avoiding eye contact d. All of the above

Answer: D Rationale: These are common signs of anxiety that comes from knowledge nursing students obtained from previous nursing courses (Psych)

The nurse manager has just received report from the previous shift. Which of the following clients should the nurse see first? a. A 35 year old admitted 3 hours ago with a gunshot wound; 1.5cm area of dark drainage noted on the dressing. b. A 43 year old who had a mastectomy 2 days ago; 23mL of sero-sanguinous fluid noted in the Jackson-Pratt drain c. A 59 year old with a collapsed lung due to an accident; no drainage noted in the previous 8 hours. d. A 62 year old who had an abdominal-perineal resection 3 days ago; client complains of chills.

Answer: D Rationale: This client is at risk for peritonitis and should be further assessed for symptoms of infection. All other clients are progressing expected. Source: Irwin, B. J. & Burckhardt J. A. (2014). NCLEX-RN 2014-2015: Strategies, practice, & review with practice test. New York, N.Y.: Kaplan Publishing. p. 285 and 338

A nursing preceptor knows the minimal informatics competencies a new orienting nurse should possess are the following: a. Implementing policies to protect patient confidentiality and privacy b. Maintain information security c. Record data relevant to nursing care d. All of the above

Answer: D Rationale: When charting, the RN should document relevant patient information in a confidential and secure manner to prevent the patient's privacy. Reference: Kaplan NCLEX book 2014-2015

A 68 year old male is admitted to an adult psychiatric unit. He has a cell phone, wedding ring, and wallet on him. What should the admitting nurse do with these belongings? a. Allow the patient to keep the items b. Ask the family member to take the items with her c. Take the belongings to the nurse's station d. Label the items in a bag with patient name and date of birth and put them in the safe

Answer:B Rationale: Having the family member take the patient's valuables home eliminates the hospital's liability for the items.

1. An unlicensed assistive personnel has witnessed an RN on a geriatric unit mistreating patients and speaking to them as if they were incompetent. After privately addressing the situation with the nurse, the nurse continued her actions. What is the best way for the UAP to handle the situation? a. Talk to another nurse on the unit about the problem behind the nurse's back. b. Ignore the situation. c. Speak to the charge nurse to resolve the issue. d. Address the situation with the unit manager.

Answer:C Rationale: Follow chain of command when experiencing issues on a unit. (Lecture notes/Class discussion).

You are a manager on a nursing unit and a staff member (RN) approaches you with concerns about caring for a patient with Ebola that was assigned to her. She appears anxious. As a manager, which action by the manager would be appropriate? a. Assign this patient to a different RN who is experienced and shows competency in infection control. b. Explain to the RN that this patient was assigned to her and the staffing assignments cannot be changed. c. Explain to the RN that she is qualified to care for this patient and she should accept this responsibility. d. Punish the RN for expressing these feelings to her

Answer: A Rationale: "The nurse manager is responsible both for the quality of the work of individual employees and for the quality of patient care in the entire unit". Sullivan p. 123

1. The nurse is caring for a client with terminal cancer of the throat. The family approaches the nurse and tells the nurse that they have spoken to the physician regarding taking their loved on home. The nurse plans to coordinate discharge planning. Which of the following services would be most supportive to the client and the family? a. Hospice care b. The American Cancer Society c. The American Lung Association d. Local religious and social organizations

Answer: A Rationale: Hospice care provides an environment that emphasized caring rather than curing; the emphasis is on palliative care. One of the major gals of hospice care is that clients be free of pain and other symptoms that do not allow them to maintain a quality of life. An interdisciplinary approach is used. Saunders Q&A Review for the NCLEX-RN Examination 5th edition.

1. The nurse calls the health care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, 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 HCP can be contacted d. Administer the recommended dose until the HCP can be located

Answer: A Rationale: If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking to the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be (Saunders, 2014).

1. A nurse manager of an ICU is interviewing a registered nurse for the team leader position. The nurse appears to be qualified and has excellent references. She states that she's certified in critical care nursing but has misplaced her verification card. Based on her knowledge of her supervisory responsibilities, the nurse manager should: a. Contact the credentialing center and confirm the nurses' certification. b. Hire the nurse, but tell her that she must provide proof of certification before completing orientation. c. Avoid hiring the nurse because she can't provide proof of certification. Trust the nurse is telling the truth because she has excellent references.

Answer: A Rationale: The nurse manager must make sure that the nurse is certified as a critical care nurse. She can do this by contacting the credentialing center. In the case of a new hire, the nurse manager must be sure that the nurse is representing herself truthfully before offering her the position.

1. A new graduate nurse has hung the wrong intravenous antibiotics for the postoperative patient. Which intervention should the nurse manager implement firsts? a. Assess the client for any adverse reactions. b. Complete the incident or adverse occurrence report. c. Administer the correct intravenous antibiotic medication. d. Notify the client's heath care provider.

Answer: A Rationale: The nurse manager should first assess the client prior to taking any other action to determine if the client is experiencing any untoward reactions. Reference - Prioritization, Delegation and Management of Care for the NCLEX RN Exam

1. A nurse calls the physician regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician, and the medication is due to be administered. Which action should the nurse implement? a. Contact the nursing supervisor. b. Administer the dose prescribed. c. Hold the medication until the physician can be contacted. d. Administer the recommended dose until the physician can be located

Answer: A Rationale: The nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be if the nurse is unable to find or contact the physician. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification. Saunders Comprehensive Review for the NCLEX-RN Examination 5th edition.

1. A nurse enters a client's room to administer ferrous sulfate 324mg. When the nurse checks the MAR against the medication, they notice that the dosage on the package indicates ferrous sulfate 300mg. Which action would be the most appropriate? a. Notify the pharmacist of the dosage error and request the correct dosage b. Administer the medication of the dosage error and request the correct dosage c. Hold the medication until the physician can be notified d. Ask the nurse who cared for the client yesterday what he or she administered to the client

Answer: A Rationale: The nurse should phone the pharmacist first to request the correct dosage for the client before it is administered (Monahan, 2010. PG 1100)

1. The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? a. The client diagnosed with a DVT who has a heparin drip infusion and a PTT of 92 b. The client diagnosed with pneumonia who has an oral temperature of 100.2 ° F c. The client diagnosed with pancreatitis who complains of pain that is an 8.

Answer: A Rationale: The therapeutic PTT level should be 1½-2 times the control. Most controls average 36 seconds, so the therapeutic levels of heparin would place the control between 54 and 72. With a PTT of 92, the client is at risk for bleeding, and the heparin drip should be held. The nurse should assess this client first (Hargrove-Huttel & Colgrove, 2009. PG 432 and 449)

Accordingly audit is now due to evaluate implementation of electronic medical record (EMR) on the unit. As the unit representative who supervised the adaptation of this documentation how can the nurse best determine if the nursing staff have accepted this change a. Nursing staff uses the EMR daily in routine documentation b. Nursing staff verbalizing need for EMR but still hand write nursing notes into the client's chart c. Nursing staff use the EMR sporadically to monitor client's progress d. Nursing staff like the EMR because they believe it saves in time

Answer: A Rationale: When people accept change and integrate it into the daily activity, the change is maintained (Hogan, 2012. PG 47)

1. A patient, who is a potential organ donor, has been admitted to the hospital with a poor prognosis. The patients' family would like to contact the recipient after the surgery. Which of the following responses by the nurse is best? a. "I will contact the transplant coordinator so she can discuss that with you." b. "The physician will have to approve it." c. "The recipient is required to contact you within 130 days." d. "You cannot contact the recipient or his family."

Answer: A Rationale: the transplant coordinator typically speaks with the family about the donor process and is available to answer all questions. Hogan, M. A., Ricci, M. J., Taliaferro, D., (2008). Nursing Fundamentals: Reviews & Rationales. (2nd ed). Upper Saddle River, NJ: Pearson Prentice Hall.

1. A registered nurse is assigned to five (5) clients for a shift. Which tasks are best delegated to a LPN? Select all that apply. a. Repositioning a NG tube on a client who has had a small bowel obstruction b. Irrigating a urinary catheter on a client from a skilled nursing facility c. Recheck vital sings on a 40 y/o asymptomatic client with a blood pressure of 100/64 d. Changing a dressing on a client with a diabetic foot ulcer in the metatarsal area e. Administer RBC to a client with a Hgb of 10.2g/dL

Answer: A&B Rationale: Scope of practice for LPNs allows them to irrigate catheters and change dressings on diabetic ulcers. Registered nurses should reposition NG tubes. Measuring blood pressure doesn't require LPN experience. RBCs should never be delegated to an LPN. (Hogan, 2012. Pg 48)

1. As a nurse manager, you have been asked to delegate the preparation of the daily staffing assignment to your assistant. The task has been determined to be one that could be delegated to someone else and free you up for other responsibilities. You recognize the experience your assistant has working on the nursing unit; you also recognize that the individual is able to hand the new responsibility. However, you find that you are unwilling to delegate the daily staffing assignment. Which answer might explain your reluctance to delegate? (select all that apply) a. You question if this is a good use of your assistant nurse manager's time and skill. b. You feel that your assistant nurse manager is already overloaded and this new assignment would just add to an already difficult situation. c. You fear that your assistant may not know all the specifics that go into developing a staffing assignment and that staff members who are used to certain patients will no longer be assigned them. d. You know that this would be an opportunity for your assistant to develop in the role of nurse manager.

Answer: ABC Rationale: A) as a nurse manager, you are expressing the feeling "I would rather do it myself"; this is a barrier to delegation. B) As a nurse manager, you have not assessed the ability of the individual to do the job or the time needed for the individual to do the activity; this is a barrier to delegation. C) The nurse manager fears the loss of control; this is a barrier to delegation. Source: McGraw-Hill Review for the NCLEX-RN page 46

1. As nurse director, you are preparing preceptors for a new group of orientating register nurses. In an endeavor for unit/task consistency and to reduce turnover of new employees the following should be placed into action? Select all that apply. a. Conduct Meyer-Briggs personality tests on preceptors and orientating personnel to group them together. b. Hold a preceptor class to check off on skills to ensure all preceptors are teaching according to unit policy c. Only provide preceptor training to new preceptors d. Prior to the ending of the orientation period the nurse manager should evaluate the orientating personnel skills and conduct survey to gather information to improve the orientation process

Answer: ABD Rationale: A. Reduces barriers to communication and understanding. B- ensures consistency D- gives new staff feedback and a voice. It also provides the manager eyes on personnel before they are on their own for patient care. pg 232-233 Effective leadership and Management in Nursing

1. Which task can be delegated to a CNA? a. Rechecking vital signs on a patient whose previous vital signs were: blood pressure of 200/120, heart rate of 50, and a respiratory rate of 30. b. Changing linens and bathing a patient. c. Inserting a catheter. d. Teaching the patient about how to clean their surgical site.

Answer: B Rationale: A care assistant can only perform bed making, bathing, feeding, ambulating, and general activities of daily living (Zerwekh & Claborn, 2006, p. 75).

1. A nurse manager of an outpatient surgery department helps groom her staff for career advancement. Which task can she safely delegate to a staff registered nurse? a. Ask one of her staff nurses to terminate a client care assistant. b. Ask two of her staff nurses to schedule staff for the next two weeks. c. Assign 24-hour responsibility to her assistant manager for a period of 2 months. d. Tell the most experienced staff nurse to select a new nursing care delivery system for use in the department

Answer: B Rationale: A nurse manager can only delegate tasks that are within the scope of practice and skill of her subordinates. Scheduling staff falls within this scope. Termination of employees and 24 hour accountability can't be delegated. The selection of new nursing care delivery system affects the functioning of an entire department and shouldn't be delegated. It should be determined by input from all staff members.

1. A nurse manager of an outpatient surgery department helps groom her staff for career advancement. Which task can she safely delegate to a staff registered nurse? a. Ask one of her staff nurses to terminate a client care assistant b. Ask two of her staff nurses to schedule staff for the next 2 weeks. c. Assign 24 hour responsibility to her assistant manager for a period of 2 months d. Tell the most experienced staff nurse to select a new nursing care delivery system for use in the department.

Answer: B Rationale: A nurse manager can only delegate tasks that are within the scope of practice and skills of her subordinates. Scheduling staff falls within this scope. A & C can't be delegated. D shouldn't be delegated. It should be determined by input from all staff members. Source: NCLEX-RN review made incredibly easy 4th edition, page 728.

1. You are the charge nurse on the Med-Surg unit. Bella is an RN on the floor. At 1100, you notice Bella has not administered her 0900 medications yet to three of her patients. What is the best action for you as the charge nurse to take? a. Pull the medications and administer them yourself b. Confront Bella and determine the cause for delay of medication administration c. Write up Bella for having a late assignment d. Assign another RN to administer the medications

Answer: B Rationale: As discussed in class, the first thing you do when you have a problem with someone is to confront them about it first. You would not want to administer the medication for the RN because it is her responsibility and you would not want to put it on you that the meds were administered late. A write up may be appropriate after the confrontation and determination. Assigning another RN would not be appropriate. Reference: Class discussion, exam 1, chapter 2 Designing Organization

A patient with DNR-DNI physicians orders experiences respiratory arrest. A competent RN understands intubation is the only effective way of establishing a patient air way. Which of the following actions should be taken first? a. Administer life saving medications. b. Assess the client for signs of death. c. Open the airway and give two breaths. d. Summon the emergency response team.

Answer: B Rationale: B. DNR-DNI indicate no extra extraordinary care be given to the client in the event of the clients death. Reference: Kaplan NCLEX review 2014-2015

A client scheduled for a small bowel obstruction repair states, "You were here when the doctor had me sign the consent form for my procedure. I thought I understood most of it but I'm still unsure about some things." Which is the best response by the RN? a. "You should have listened more closely." b. "You sound as if you would like to ask more questions." c. "I will get you a pamphlet" d. "That often happens when this procedure is explained to patients."

Answer: B Rationale: B. This directly responds to the patient's concerns. Any questions should be acknowledged and answered accordingly. Reference: Kaplan NCLEX review 2014-2015

1. Staff assignments have been made for the shift and bedside reporting is complete. After morning med pass, a 51 year-old female patient incontinent of bowel and bladder, tells the UAP that she is uncomfortable having a male nurse. The UAP informs the nurse and the charge nurse. What does the charge nurse do regarding reassignment of the patient? a. Informs the patient that all personal care needs will be performed by the UAP, so having a male nurse is not an issue b. Collaborates with the male nurse and a female nurse regarding changing patients and reassigns accordingly c. Contacts the legal department to see if the patient can be forced to keep the male nurse d. Tells the patient that there are plenty of male nurses in today's society and that she should find ways to cope with her prejudice

Answer: B Rationale: Beneficence

5. What is considered the most effective means for resolving conflicts? a. Negotiation b. Confrontation c. Accommodation d. Collaboration

Answer: B Rationale: Confrontation is the most effective means for resolving conflicts (Sullivan, 2013. Page 166)

1. A charge nurse is assessing the physical status of several patients. Which patient problem should be the nurses greatest concern? a. Tenting of skin b. Difficulty breathing c. Erythema over the greater trochanter d. Body weight inadequate in relation to height

Answer: B Rationale: Ensuring adequate gas exchange is the priority; inadequate gas exchange is life threatening. (Nugent & Vitale, 2014, p. 800 & 816)

1. Ana, a nurse manager wants to evaluate a new nurses' ability to draw up the medication IV Protonix correctly. What is the best way for Ana to evaluate this staff member? a. Have the new nurse draw up the medication and bring it to her in the syringe so that she can confirm the amount b. Ana should confirm the dose and stand beside the new nurse and watch her as she draws up the medication c. Have the new nurse go with her friend on the floor, who is another nurse to draw up the medication d. The new nurse tells you that she knows how to draw up medications and you assume that she does

Answer: B Rationale: Found in Eleanor J. Sullivan's Effective Leadership and Management in Nursing, Chapter 18, Evaluating Staff Performance, p. 247 under "Evaluating Skill Competency" it says "Skill evaluation most commonly takes place in a skills lab, with simulation models, or by direct observation at the point of care. The manager plays a key role in determining the competences required on the job, especially for unit or department-specific competencies." This answer would be correct because it is direct observation at the point of care if the manager confirms the dose and watches the nurse draw up the medication.

1. The staff nurse is concerned about possible increasing infection rates among clients with peripherally inserted central catheters (PICCs). The nurse has noticed several clients with problems in the past few months. Which action would be appropriate for the staff nurse to implement first? a. Discuss the infections with the chief nursing officer b. Contact the infection control nurse to discuss the problem c. Assume the employee health nurse is monitoring the situation d. Volunteer to be on a committee to research the infection rate

Answer: B Rationale: Possibly increasing infection rates among clients with PICCs falls within the infection control nurse's scope of practice and the infection control nursing staff will have the data from all units in the hospital (Hargrove-Huttle & Colgrove, 2009. PG 32 & 38).

1. The client admitted to the critical care unit tells the nurse, "I have an advance directive (AD) and I do not want to have cardiopulmonary resuscitation (CPR)." Which intervention should the nurse implement first? a. Ask the client for a copy of the AD so that it can be placed in the chart b. Inform the healthcare provider of the client's request as soon as possible c. Determine whether the client has a durable power of attorney for healthcare d. Request the hospital chaplain to come and talk to the client about this request

Answer: B Rationale: Prioritization, Delegation, & Management of Care for the NCLEX-RN Exam page 113. The nurse should first inform the HCP so the order can be written in the client's chart. The HCP must write the do not resuscitate (DNR) order before the client's wishes can be honored.

As the manager, what would you do first if a nurse is suspected of diversion of medication? a. Contact ASBN & request an investigation b. Confront the suspected nurse to clarify c. Question other RNs that work closely with the suspected nurse d. Interview the nurse in the same room with those who reported the diversion

Answer: B Rationale: Professionalism would be making sure to go to the individual nurse first. Reference: Management lecture/discussion

A nursing team consists of an RN, an LPN, and a UAP. The nurse manager should assign which of the following clients to the RN due to their change in condition? a. A 72 year old client with diabetes who has had a stasis ulcer for the last 3 days, the orders now say that the dressing should be changed BID as opposed to daily b. A 42 year old client with dehydration that is having their IV fluids discontinued and is expected to be discharged later that day with no anticipated medication or regimen changes c. A 55 year old client with brain cancer that was alert and oriented yesterday that is now confused, combative, and hypertensive. d. A 23 year old client with a fracture of the right lower leg that is asking to use the urinal standing.

Answer: B Rationale: The clients in questions A and C are stable without changes in care that require skills that are limited to an RN scope of practice (assessments, education, etc.) The client in question D has no change in care and the UAP could assist with this client's activities of daily living. The client in question B is exhibiting signs of a change in level of consciousness and would require RN assessment skills. Source: Irwin, B. J. & Burckhardt J. A. (2014). NCLEX-RN 2014-2015: Strategies, practice, & review with practice test. New York, N.Y.: Kaplan Publishing. p. 112

The nurse manager discovers that the last dose of intravenous antibiotics that was supposed to be administered to a client was missed. Which of the following should the nurse manager do? a. Document the event in the client's medical record only and give the nurse a written reprimand for the incident. b. File an incident report, and document the event in the client's medical record. Speak with the patient's primary nurse about why the medication was missed to prevent further errors. c. Document in the client's medical record that an incident report was filed. Commend the primary nurse on documenting that the missed medication was given so that they won't get in trouble about it later. d. File an incident report, but don't document the event the client's medical record so that if an adverse event occurs the papers will look better in court. Collaborate with the primary nurse to make sure everyone has the same story.

Answer: B Rationale: The event should be filed in an incident report (for internal records - so that learning for the institution may occur) and in the client's medical record (for client's records). But the nurse manager should also speak to the nurse responsible about why the incident occurred and they should also work on strategies/processes' to prevent this from happening again. Source: Irwin, B. J. & Burckhardt J. A. (2014). NCLEX-RN 2014-2015: Strategies, practice, & review with practice test. New York, N.Y.: Kaplan Publishing. p. 141 & 148

Following a shift report on an oncology unit, a nurse determines that which client should be assessed first? a. A client with breast cancer who has an order for ondasetron (Zofran) 8mg intravenously 30 minutes prior to chemotherapy b. A client just admitted with a temperature of 101F, diaphoresis, and an absolute neutrophil count of 98/mm3 c. A client with breast cancer who is scheduled for external beam radiation in 15 minutes d. A client with stomatitis associated with tonsilar cancer who receives gastrostomy tube feedings

Answer: B Rationale: The newly admitted client should be assessed first because the client is neutropenic, showing signs of infection, and microorganisms from the other clients would be less likely to be transmitted to the client if seen first. The client should be placed on neutropenic precautions. The client is at risk for severe sepsis if the absolute neutrophils count is less than 100/mm3" (Ohman, K., 2010, p. 337)

1. When a nurse manager is checking charts for appropriate documentation, which of the following documentations regarding the administration of a medication is recorded accurately according to the Joint Commission? a. Coumadin 5 mg QOD for 7 days b. Heparin 5,000 units Sub-Q daily c. MgSO4 1.0 g for hypertension d. Calcium 600 mg po qd

Answer: B Rationale: The use of Sub-Q for subcutaneously is not disallowed by the Joint Commission. (Nugent & Vitale, 2014, p. 141 & 147)

1. The nurse manager needs vital signs obtained and reported for a client, every 4 hours. This client should also be turned every 2 hours. The nurse manager has decided to delegate these tasks to a UAP. How should the nurse instruct the UAP to complete these tasks? a. Catch the UAP on break and tell her the tasks to be completed b. Write down detailed instructions, including documentation, to give to the UAP c. Assume the UAP will see the orders in the patient's chart d. None of the above. These tasks are not within the UAP's scope of practice

Answer: B Rationale: These tasks are within the UAP's scope of practice. Detailed instructions should be written and given to the staff member completing the task, as to eliminate confusion about tasks. (ASBN rules of delegation)

A patient's primary nurse has come to the nurse manager to ask about an ethical dilemma. A 20 year-old patient with leukemia has consented to a blood transfusion against the wishes of his family, who are all Jehovah's Witnesses. The nurse manager knows that according to the ethical principle of autonomy that the nurse should... a. Hold the blood transfusion until the family can come to an agreement to prevent undue stress on the patient. b. Give the blood transfusion because the client has the right to make decisions for themselves. c. Refuse to take any action until the family accepts the clients wishes d. Give the blood transfusion, but tell the family it is a medication and not blood.

Answer: B Rationale: This answer respects the clients autonomy (ability to make their own decisions), not giving the transfusion goes against the clients wishes, and lying to the family violates the ethical principal of veracity. Source: Irwin, B. J. & Burckhardt J. A. (2014). NCLEX-RN 2014-2015: Strategies, practice, & review with practice test. New York, N.Y.: Kaplan Publishing. p. 119 and 125

1. A nurse receives a telephone call from the emergency department and is told that a child with a diagnosis of tonic-clonic seizures will be admitted to the pediatric unit. The nurse prepares for the admission of the child and instructs the nursing assistant to place which items at the bedside? a. a tracheostomy set and oxygen b. suction apparatus and an airway c. an endotracheal tube and an airway d. an emergency cart and laryngoscope

Answer: B Rationale: Tonic-clonic seizures cause tightening of all body muscles followed by tremors. Obstructed airway and increased oral secretions are the major complications during and after a seizure. Suction is helpful to prevent choking and cyanosis. Options 1 and 3 are incorrect because inserting an endotracheal tube or a tracheostomy is not done. It is not necessary to have an emergency cart (which contains a laryngoscope) at the bedside, but a cart should be available in the treatment room or on the nursing unit. If a child is experiencing a seizure, the priority is to ensure a patent airway. (Saunder's Q&A Review)

1. Evidence-based practice has been established to advance nursing practice. The goals for this practice have been to: a. Reduce health care costs and improve health care. b. Facilitate the highest quality of care and the best client outcomes. c. Encourage increased research utilization in nursing practice. d. Evaluate research findings and scientific evidence to a specific clinical question.

Answer: B Rationale: Using nursing research allows for continuing improvement in health care practices. Being able to continue to improve practices allows nurses to give the highest quality of care and can facilitate the best client outcomes. Pearson Chapter 10 NCLEX Review Questions.

1. Jill is the charge nurse on the Med-Surg unit. Sam is the CNA whose assignment is to complete bed baths. An hour before shift change, Jill finds that Sam has not completed his assignment and has been sitting at the nursing station for the past hour. What is the best action for the charge nurse to take? a. Terminate Sam for his incomplete assignment b. Meet with Sam privately and determine the cause of the incomplete assignment c. Talk to the floor manager d. Speak with other nurses to tell them about how lazy Sam is

Answer: B Rationale: When there is a problem with a staff member, the appropriate action to take is to speak with the person whom you have an issue with first. If that person still continues to cause problems after the confrontation, one should then follow their chain of command to get the issue resolved. Reference: class discussion, exam 1, chapter 2 Designing Organization

You are a nurse manger for the emergency department. What triage color would you assign to a patient that is alert and oriented with a suspected simple fracture? a. Red b. Yellow c. Green d. Blue

Answer: B Rationale: Yellow classification is assigned to patients who require treatment and whose injuries have complications that are not life-threatening, provided they are treated within 1 to 2 hours. Examples include: simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone. Saunders comprehension exam review page 76

A 45 year old male patient is admitted to the floor after a scheduled wound debridement. There are orders to change the surgical dressing for the first time in 24 hours. As a manager, who would you delegate this task to? a. Only the surgeon can remove the dressing b. The RN c. The LPN d. The UAP

Answer: B Rationale: it is within the RN's scope of practice to complete the first dressing change and assess the wound initially.

1. ____________ is an evaluation method used to inspect the medical record after the client's discharge for documentation of compliance with the standards. a. Concurrent audit b. Retrospective audit c. Peer review d. Trending evaluation

Answer: B Rationale: this is simply the definition of a Retrospective Audit; Saunders comprehensive NCLEX-RN exam review, p. 68

1. A nurse is developing an educational session on client advocacy for the nursing staff. The nurse plans to tell the nursing staff that which of the following are examples of the nurse acting as a client advocate. Select all that apply. a. Obtaining an informed consent for a surgical procedure. b. Providing information necessary for a client to make informed decisions. c. Providing assistance in asserting the client's human and legal rights if the need arises. d. Telling the client that he or she will need to defend him or herself about health care rights. e. Defending the client's rights by speaking out against policies or actions that might endanger the client's well being.

Answer: BCE Rationale: In the role of client advocate, the nurse protects the client's human and legal rights and provides assistance in asserting those rights if the need arises. The nurse advocates for the client, keeping in mind the client's religion and culture. The nurse also defends clients' rights in a general way by speaking out against policies or actions that might endanger the client's well-being or conflict with his or her rights. Saunders Q&A Review for the NCLEX-RN Examination 5th edition.

1. Nurse Belle is assigned two patients. Patient A is in contact isolation while patient B is not. Which of the following is necessary to prevent cross-contamination? SELECT ALL THAT APPLY a. Use only foam hand sanitizer between each patient. b. Utilize PPE c. Follow standard precautions d. Wash your hands thoroughly with soap and water between each patient.

Answer: BD Rationale: If a patient is placed in isolation PPE is necessary for safety and contamination prevention. Washing your hands with soap and water is necessary with some illnesses/disease processes to kill the bacteria (Billings & Hensel, p.390)

1. The nurse is caring for a client who was involuntarily hospitalized and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination? a. The informed consent does not need to be obtained. b. The informed consent should be obtained from the family. c. The informed consent needs to be obtained from the client. d. The health care provider will provide the informed consent.

Answer: C Rational: Clients who are admitted involuntarily do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client. (Silvestvi, 2014)

1. A client is scheduled for surgery and the surgeon has explained the procedure and is about to obtain informed consent. Which statement by the client would indicate to the nurse that the client needs more information before giving informed consent to the procedure? a. "If you don't have this surgery, then the tumor will grow." b. "You said you will remove the tumor but will not be removing the entire breast." c. "I know my surgeon explained it, but I still don't know why surgery is needed." d. "I'll have some pain after the surgery, but it should get better with that tumor gone."

Answer: C Rational: Informed consent must be obtained before surgery can be legally preformed. The nurse acts as an advocate to make sure that the client understands what the health care provider has explained about surgery. The client must receive information about the purpose of the surgery, other options if surgery isn't done, risks of surgery, and benefits. Options 1,2, and 4 identify an understanding by the client whereas option 3 indicates that the client needs more information. (Silvestvi, 2014)

1. Ashley, RN is extremely busy and has 3 central line dressings to change, a patient that wants water, a patient that wants feed and 2 patients that need to be transferred to another floor. You have 2 UAP's and 1 LPN. What can you delegate to the LPN? a. Get the patient water b. Change the 3 central line dressings c. Transfer the two patients to another floor. d. Feed the patient

Answer: C Rationale: According to Sullivan the LPN can transfer patients to another floor Source: Effective Leadership Management in Nursing (Sullivan, pg. 132)

1. During a continuing education seminar, Nurse Lydia provides each of the four groups of medical personnel with a scenario to discuss regarding patient advocacy. Which of the following demonstrates an appropriately handled situation that illustrated intact patient advocacy? a. Patient A has asked for pain medication. The nurse prepares and goes into the room to administer the medication, and finds him sleeping. Instead of administering the medication she wastes it. b. Patient B requests more pain medication only an hour after receiving an oral dose. Nurse Dawn dismisses his request. Stating, He just likes that IV medication. c. Patient C is a vegetarian but receives chicken and rice on her dinner tray. Nurse Ryan called dietary to obtain a new tray suitable to dietary restrictions. d. Patient D is a Muslim and his religion requires specific prayer times. The physician orders a MRI, and the nurse schedules it during one of these times. The patient tries to explain to the nurse the importance of his prayer schedule, and she interrupts him; stating "This isn't the Hilton".

Answer: C Rationale: Advocacy is important. Patient's rights and choices need to be protected. It is the nurse's responsibility to respect and defend the patient's choices; especially lifestyle and religious decisions. (Classroom discussion)

1. The charge nurse is planning assignments. Which client should be given to the LPN? a. A client who just arrived to the floor and needs an initial assessment done. b. A patient who has an order for a blood transfusion. c. A patient 3 days post-op of a bilateral knee arthroplasty that will be discharged the next day. d. A patient whose blood pressure is 76/48, heart rate 120, temperature of 101.2, and a white blood cell count of 20,000.

Answer: C Rationale: An LPN can only perform tasks that include: nursing actions, sterile technique, medication administration, and implementing basic nursing process after a nurse has evaluated. Only an RN can use nursing judgment required for unstable clients (Zerwekh & Claborn, 2006, p. 75).

9. The charge nurse on the night shift reports that the narcotic count is incorrect. The nurse has spoken to the responsible staff nurse and believes that substance abuse by the nurse is the cause. If substance abuse is the case of the incorrect count. What is the appropriate next step? a. Recount the narcotics with the staff nurse and take disciplinary action b. Ask the staff nurse to leave the unit and report the incident to the ANA c. Complete and incident report and report the findings to the pharmacy and nursing administration d. Submit the findings to the council on nursing practice

Answer: C Rationale: An incident report must be completed because of inaccurate count of narcotics or controlled substances fall under federal law and regulation (Hogan, 2012. PG 27)

1. You are the charge nurse in the ICU. As you are reviewing the documented assessments, you notice several of the new ICU staff members are failing to document correctly. As the leader of the unit, what should you do to correct this problem? a. Criticize the staff members about wrongly documenting assessments b. Do not allow the staff members to document c. Hold an in-service to review the process of documentation on the program d. Ignore the problem

Answer: C Rationale: As the leader of the floor, it is your responsibility to ensure that documentation is done correct, and that proper documentation methods are being taken. If a problem is occurring with multiple staff members, the best thing to do is hold an in-service to educate the staff members. Reference: class discussion, Chapter 19 - coaching staff

1. A nurse is transcribing orders for a client and finds a new order for aspirin. The nurse knows that the client has a long history of gastrointestinal bleeding. What action should the nurse take? a. Withhold the medication and chart why it was not given b. Ask the client if she is allergic to aspirin c. Call the physician and question the order in light of the history d. Give the medication and observe the client's response

Answer: C Rationale: Because the nurse knows the client's history, the nurse should notify the physician of the client's history and ask for a change in medications (Claborn & Zerwekh, 2006).

1. A clinical nurse manager conducts an inservice educational session for the staff nurses about case management. The clinical nurse manager determines that a review of the material needs to be done if a staff nurse stated that case management: a. manages client care by managing the client care environment b. maximizes hospital revenues while providing for optimal client care c. represents a primary health prevention focus managed by a single case manager d. is designed to promote appropriate use of hospital personnel and material resources

Answer: C Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal client care. It manages client care by managing the client care environment and includes assessment and development of a plan of care, coordination of all services, referral, and follow-up. (Saunders Q&A review)

1. The nurse on the hospital quality improvement team has been asked to evaluate nursing care on the nurse's assigned unite. After deciding to ask the nursing staff for assistance in this effort, what would be most appropriate for the nurse to initially ask the staff to do? a. Track the number of supplies used by clients on the unit b. Document the time spent on direct client care c. Administer a client and family satisfaction survey d. Assess clients and report acuity daily

Answer: C Rationale: Client satisfaction surveys are an important tool to monitor and evaluate client and family needs; Comprehensive review for NCLEX-RN Pearson reviews and rationales. 48

1. Using a mannequin, a nurse has demonstrated wound care for a client. To validate client learning, which of the following would be the best nursing action at this time? a. Complete wound care on the client, explaining the procedure while performing it. b. Show a video explaining the sterile technique to be used for the client's wound care. c. Have the client perform wound care with the nurse present to supervise. d. Ask the client to review written client education literature and perform would care at the next scheduled time.

Answer: C Rationale: Clients are more likely to successfully complete a new procedure if they can actively demonstrate the procedure immediately after instructions have been given with the nurse present the first several times. Written literature and a video do not allow for active participation; however they can be used as supplementary learning aids. Hogan, M. A., Ricci, M. J., Taliaferro, D., (2008). Nursing Fundamentals: Reviews & Rationales. (2nd ed). Upper Saddle River, NJ: Pearson Prentice Hall

1. A group of physicians are in conflict with the nursing staff of a geriatric unit over when AM vital signs are recorded. To resolve the conflict, what type of technique might be used that respects the professionalism of both parties? a. Avoiding. b. Suppression. c. Collaboration. d. Intervention.

Answer: C Rationale: Collaboration implies mutual attention to the problem, as the talents of all parties are used. (Effective Leadership and Management Website, Ch. 12).

1. The nurse enters data on a chart and discovers she has written on the wrong chart. How is this error best corrected? a. White out the wrong information and write over it b. Recopy the page with the error so the chart will be neat c. Draw a straight line through the error, initial, and date d. Obliterate the error so it will not be confusing

Answer: C Rationale: Errors in charting should never be obliterated, recopied, or covered with correction fluid. When the erroneous information is not legible, it raises questions as to what the person was trying to cover up (Claborn & Zerwekh, 2006. PG 77)

Jennifer, a nurse and case manager, has a patient who has had a stroke but is regaining strength daily. The patient and her family want the patient to achieve independence again, but the patient will still need help achieving independence again outside the hospital. What are the best resources available to help the patient achieve independence again? a. Send the patient to the nursing home b. Send the patient home and ask her family to assist her until she can follow up with her primary care physician c. Send the patient to a rehab facility where she can have access to physical therapy and occupational therapy d. Keep the patient in the hospital until she achieves 100% independence

Answer: C Rationale: Found in Eleanor J. Sullivan's Effective Leadership and Management in Nursing, Chapter 3, Delivering Nursing Care, p. 34, Under the section titled "Case Management" it says "In an acute care setting, the case manager has a caseload of 10 to 15 patients and follows patients' progress through the system from admission to discharge, accounting for variances from expected progress. One or more nursing case managers on a patient care unit may coordinate, communicate, collaborate, problem solve, and facilitate patient care for a group of patients." Answer C is correct because the case manager has followed this patient throughout her care and knows that sending the patient to a rehab facility where she can have access to physical therapy and occupational therapy is where the patient is most likely to achieve independence again.

A client is brought to the emergency department by EMS after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the procedure, which is the best action? a. Obtain a court order for the procedure. b. Ask the EMS to sign the informed consent. c. Transport the victim to the OR for surgery. d. Call the police to identify the client and locate the family.

Answer: C Rationale: In general, there are two situations in which informed consent is not required. One is when an emergency is present and delaying treatment for the purpose of informed consent would result in injury or death of the client. Saunder's Comprehensive Review for the NCLEX

1. A client who is scheduled for surgery is brought to the surgical unit. The client hands the nurse the information about advance directives he received from the admitting nurse and says, "Here, I don't know why she gave me this stuff. I'm too young to worry about what life-sustaining measures I want done for me." Which action should the nurse make next? a. Take the papers and send them back to the admitting department with a note stating that the client does not wish to address this issue at this time. b. Explain to the client that you never know what can happen during surgery and that he should fill the papers out "just in case." c. Contact a client representative to talk with the client and offer additional information about the purpose of advance directives. d. Inform the client that surgery cannot be conducted unless he completes the advance directives forms.

Answer: C Rationale: It is important that the client be properly informed about the purpose of advance directives and their role in protecting his rights. While the client is not required to fill out the papers, his comments indicate he might not understand their purpose, and the nurse must advocate for him to ensure his rights are protected. The nurse, however, should never coerce a client into signing any legal forms, even if she believes it would be in the client's best interest. Reference - Pearson: Understanding the Essential of Critical Care Nursing (Chapter 18)

1. The charge nurse on the night shift reports that the narcotic count is incorrect. The nurse has spoken to the responsible staff nurse and believes that substance abuse by the nurse is the cause. If substance abuse proves to be the cause of the incorrect count, what is the most appropriate next step? a. Recount the narcotics with the staff nurse and take disciplinary action b. Ask the staff nurse to leave the unit and report the incident to the American Nurses Association c. Complete an incident report and report findings to the pharmacy and nursing administration d. Submit the findings to the Council on Nursing Practice

Answer: C Rationale: Narcotics are federally regulated by the government and misuse is considered a federal offense; Comprehensive review for NCLEX RN Pearson reviews and rationales, p. 47

1. While caring for an 8 y/o child with a wrist fracture; the primary nurse notices red raised streaks on her back. The father enters the room and the child becomes quiet and drops her gaze. What is the nurse's best action in the role of a patient advocate? a. Chart in the nurses' notes that the child has been beaten by her father. b. Accuse the father and threaten to call the police c. Notify the house supervisor and follow the chain of command to report suspected abuse. d. No action is required. There is not any evidence the father is at fault for the markings.

Answer: C Rationale: Nurses are mandatory reporters of abuse. Only facts should be placed in the charted documentation. (Zerwekh & Claborn, p. 79)

7. The client has just been told the medical condition can't be treated successfully and the client has a life expectancy of 6 months. Which referral would the nurse make at this time? a. Home Health nurse b. To the client's pastor c. To a hospice agency d. To the social worker

Answer: C Rationale: One of the guidelines for admission to a hospice agency is a terminal process with a life expectancy of 6 months or less. These organizations work to assist the client and family to live life to its fullest while providing for comfort measures and a peaceful, dignified death (Hargrove-Huttle & Colgrove, 2009)

A newly hired Licensed practical nurse (LPN) asks you, the nurse manager, what SBAR stands for. What is the most appropriate response: a. Subjective, background, assessment, restrictions b. Situation, basic knowledge, assessment, recent history c. Situation, background, assessment, recommendation d. Subjective, baseline vital signs, assessment, recommendation

Answer: C Rationale: SBAR is an important tool when communicating with other nurses during shift change, and when consulting a health care provider. This is a framework for communicating critical patient information in a systemized and organized fashion. It stands for situation, background, assessment, and recommendation. P. 93 Weiss & Tappen

The community health nurse is working with disaster relief personnel after a hurricane that ruined many homes in the local community. The nurse is working to find housing for the survivors and organizing counseling services. Which prevention level does the nurse's action represent? a. Primary b. Secondary c. Tertiary d. Quaternary

Answer: C Rationale: Tertiary prevention involves reduction of the amount and degree of disability, injury, or damage after a crisis. found in Saunder's Comprehensive Review for the NCLEX

1. A UAP comes to you, the nurse manager, reporting that she saw an LPN break policy and that the family is complaining about the delivery of care. What will be your first action? a. Immediately write an incidence report b. Tell the family that the LPN will be disciplined immediately c. Talk to the LPN about her actions d. Ignore the UAP's report

Answer: C Rationale: The chain of command should be followed, which means the staff member should be confronted before any other actions are taken. (Sullivan)

A charge nurse walks by a patient's room where a nursing assistant just walked out of. The bed side rails are all down and the bed is not in the lowest positon. What should the charge nurse do regarding the nursing assistant? a. Ignore it. b. Talk to the nursing assistant in front of the nursing staff about the incident c. Take aside the nursing assistant and discuss the safety regarding the side rails and the level of the bed. d. Yell at the nursing assistant for not doing their job properly.

Answer: C Rationale: The charge nurse should maintain professionalism and not embarrass the nursing assistant in front of others when discussing and properly educating the nursing assistant. Source: Sullivan, E. J. (2012). Effective leadership and management in nursing. Boston: Pearson.

A nurse is caring for a client who is being prepared for surgery. The client hands the nurse information about advance directives and states, "Here, I don't need this. I am too young to worry about life-sustaining measures and what I want done for me." Which of the following actions should the nurse take? a. Return the papers to the admitting department with a note stating that the client does not wish to address the issue at this time. b. Explain to the client that you never know what can happen during surgery and that he should fill the papers out "just in case." c. Contact a client representative to talk with the client and offer additional information about the purpose of advance directives. d. Inform the client that surgery cannot be conducted unless he completes the advance directives forms.

Answer: C Rationale: The nurse should advocate for the client by ensuring that the client understands the purpose of advance directives. Seeking the assistance of a client representative to provide information to the client is an appropriate action. Source: http://www.atitesting.com/ati_next_gen/FocusedReview/data/datacontext/RM%20L&M%206.0%20Chp%203.pdf

1. The infection control nurse notices a rise in nosocomial infection rates on the surgical unit. Which action should the infection control nurse implement first? a. Hold an in-service for the staff on proper method of hand washing. b. Tell the unit manager to decide on a corrective measure. c. Arrange to observe the staff at work for several shifts. d. Form a hospital-wide quality improvement project.

Answer: C Rationale: This is an action that will allow the infection control nurses to observe compliance with standard nursing practices such as had washing. One the nurse has attempted to determine a cause, then corrective action can be implemented. Source: Prioritization, Delegation and Management of care for the NCLEX-RN exam pg. 278

A nurse was recently caught diverting narcotics. In evaluating the effectiveness of the floor director's intervention, the nurse correctly states: a) Next time, I won't get caught b) I will only take medications that isn't life-altering to my patients c) I will no longer steal patients' medications and will take any disciplinary actions required d) I will only steal from unconscious patients, they will never know

Answer: C Rationale: Urging the substance-abusing colleague to quit it not enough and, in some cases, not appropriate. Disciplinary action is taken by the state board of nursing" (Meyers, J., 2013, p. 524).

1. A patient was admitted to the hospital with active tuberculosis. A RN is in charge of assigning this patient's room. Which room would be the most appropriate room for the patent with tuberculosis? a. A regular private room b. With a patient with pneumonia c. A negative-pressure room d. With a patient with a broken leg

Answer: C Rationale: a patient that is diagnosed with active tuberculosis should be placed in a negative-pressure room with respiratory isolation; to maintain negative pressure, the door of the room must be tightly closed. Source: Silvestri, L. A. (2011). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier/Saunders

1. A patient is gravely ill, possibly dying and comatose. His nurse is speaking with his son who has durable power of attorney for health care. Which of the following would be the most appropriate way for the nurse to initiate a discussion regarding possible interventions? a. Did your father describe to you exactly what he wanted done when he appointed you his durable power? b. Do you want to have everything possible done to care for your father? c. Have you thought about what you could do if this treatment does not to work and if he does not get better? d. What would you want to have done if you were the person who was ill and possibly dying?

Answer: C Reference - Pearson: Understanding the Essential of Critical Care Nursing (Chapter 18)

A client who is on reverse isolation for immunosuppression is two rooms away from a client that is on isolation for an MRSA infection. Which assignment should the nurse manager make? a. Assign both patients to the same nurse so they don't have to walk so far. b. Assign both patients to the same nurse to keep all the isolation patients with a "dirty" nurse. c. Assign clients to different nurses because an immunosuppressed client will require a higher level of care and should be placed on 1 to 1 nursing care. d. Assign clients to different nurses because a nurse should not have clients that are immunosuppressed and clients with active communicable infections

Answer: D Rationale: "A client who is immunosuppressed and a client with MRSA shouldn't be assigned to the same nurse." (p. 76) Source: Zerwekh, J. & Claborn, J.C. (2006). Illistrated study guide for the NCLEX-RN exam (6th ed.). Philadelphia, P.A.: Mosby Inc. p. 76

1. When quality improvement is part of the philosophy of a health care agency, which staff members are involved in ways of improving client care and outcomes? a. The RN, UAP, and LPN only b. The RN, UAP, LPN, and case manager only c. The RN only d. Every staff member is involved

Answer: D Rationale: Every staff member is involved in the quality improvement of patient care when it is the part of the philosophy of a health care agency; Saunders comprehensive NCLEX-RN exam review, p. 68)

1. A registered nurse arrives at work and is told to report (float) to the ICU for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take what action first? a. Call the hospital lawyer b. Refuse to float to the ICU c. Call the nursing supervisor d. Report to the ICU and identify tasks that can be performed safely.

Answer: D Rationale: Floating is an acceptable legal practice used by hospitals to solve understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action. Source: Silvestri, L. A. (2011). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier/Saunders

1. Brenda, a nurse manager wants to evaluate a new nurse's time management skills. What is the best way for Brenda to evaluate this staff member a. Have the new nurse keep a log throughout the day of the tasks that she completes and have her write down at what time she completes the tasks b. Have another nurse on the floor, who is the new nurses friend, check off tasks as the new nurse completes them throughout the day c. Have the new nurse tell you at the end of the day when she completes a list of tasks d. Give the new nurse a number of tasks to complete within an hour and observe the nurse as she prioritizes the tasks and completes them

Answer: D Rationale: Found in Eleanor J. Sullivan's Effective Leadership and Management in Nursing, Chapter 18, Evaluating Staff Performance, p. 247 under "Evaluating Skill Competency" it says "Skill evaluation most commonly takes place in a skills lab, with simulation models, or by direct observation at the point of care. The manager plays a key role in determining the competences required on the job, especially for unit or department-specific competencies." This answer would be correct because it is direct observation at the point of care if the manager observes the nurse as she prioritizes the tasks and completes them.

1. When making room assignments for an RN caring for an HIV patient, which patient should be assigned to another nurse? a. A patient with arterial fibrillation b. A patient with metastatic lung cancer c. A patient who recently underwent an ORIF that morning d. A patient diagnosed with the flu

Answer: D Rationale: Health maintenance in the HIV/AIDS population is significantly different from that in the general population because of the lethal threat of opportunistic infections. Considerable effort must be made to protect against infections and to detect them early" (Meyers, J., 2013, p. 253). Influenza is a contagious disease that could potentially be life-threatening for an immunocompromised patient.

1. 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 understands that planning care delivery will be based on which characteristic of this type of nursing model of practice? a. a task approach method is used to provide care to clients b. managed care concepts and tools are used in providing client care c. a single RN is responsible for providing care to a group of clients d. an RN nurse leads nursing personnel in providing care to a group of clients.

Answer: D Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

1. A nurse is providing a newly diagnosed diabetic with information about her new medication. The nurse is performing which nursing role? a. Delegation b. Mandatory reporter c. Patient advocate d. Patient educator

Answer: D Rationale: In this scenario, the nurse is acting as a patient educator by instructing the patient on her new medications. Hogan, M. A., Ricci, M. J., Taliaferro, D., (2008). Nursing Fundamentals: Reviews & Rationales. (2nd ed). Upper Saddle River, NJ: Pearson Prentice Hall.

11. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? a. Performing a procedure without consent b. Threatening to give a client a medication c. Telling the client that he or she cannot leave the hospital d. Observing care provided to the client without the client's permission

Answer: D Rationale: Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs (Saunders, 2014)

1. A 90 year old male client was recently widowed after more than 60 years of marriage. The client was admitted to a long-term care facility and is refusing to eat. Which intervention is an example of the ethical principal of autonomy? a. Place a nasogastric feeding tube and feed the client b. Discuss why the client does not want to eat anymore c. Arrange for the family to bring food for the client d. Allow the client to refuse to eat if he wants to

Answer: D Rationale: Prioritization, Delegation, & Management of Care for the NCLEX-RN Exam page 50. This is an example of autonomy

1. How can a nurse manager use him/herself to provide information to staff? a. Orientation of individuals to facility b. Performing an inservice on needed information c. On-the-go job training of needed information d. All of the above

Answer: D Rationale: Staff education is the process of enhancing staff performance and by utilizing the nurse manager to educate staff can keep staff members current with protocol (Monahan, 2010. PG 42)

4. The RN must delegate care of an assigned client to an UAP for the shift. Which client would be best to delegate to the UAP? a. A client who would benefit from talking about the recent death of her husband b. A client with urinary drainage catheter and NG tube feedings who is on bedrest c. A client with an ostomy who has persistent problems with leakage d. A client who was transferred from the ICU 3 days ago and is ambulatory

Answer: D Rationale: The ambulatory client is best to delegate because the client is likely to be stable with a low level of unpredictability. (Hogan, 2012. Page 47)

12. The primary nurse overhears the UAP telling a family member of a client, "One of the clients at the rehab unit will be going to prison because that person was charged with vehicular manslaughter because two people in a motor vehicle accident died." What action should the primary nurse implement first? a. Apologize to the family member for the UAPs comments b. Tell the UAP that the comment is a violation of HIPAA c. Allow the UAP to complete the conversation then discuss the situation d. Interrupt the conversation and tell the UAP to go to the nurses' station

Answer: D Rationale: The is a violation of HIPAA and is gossiping about another client (Hargrove-Huttel & Colgrove, 2009)

1. A floor in a hospital is having issues with nurses not properly calibrating glucometers. What is the most effective way to educate the nursing staff on the importance of glucometer calibration? a. Send out staff wide email. b. Put a flyer on the bulletin in the break room. c. Send a message to the staff on Facebook. d. Hold a mandatory inservice on how and why glucometers need to be calibrated.

Answer: D Rationale: The most intimate form of contact is face to face. The more important or delicate the issue is, the more intimate the form of contact should be (Sullivan, 2009, p. 118).

8. The female volunteer on a medical unit tells the nurse that one of the clients on the unit is her neighbor and asks about the client's condition. Which information should the nurse discuss with the volunteer? a. Deteremine how well she knows the client before talking to the volunteer b. Tell the volunteer the client's condition in layman's terms c. Ask the client if it's alright to talk to the volunteer d. Explain the client info is on a need to know basis

Answer: D Rationale: The nurse should remind the volunteer of the HIPAA and confidentiality rules that govern any information concerning clients healthcare will be shared on a need to know basis (Hargrove-Huttle, Colgrove, 2009)

1. A Jehovah's Witness is admitted to the hospital with upper GI bleeding. The physician orders two units of packed red blood cells administered over 2 hours each. When the nurse tells the client about the order, the client refuses the transfusion. How should the nurse proceed? a. Follow the physician's order and administer the transfusion b. Tell the client that she's being ridiculous because she'll die without the transfusion. c. Refuse to care for the client because you don't agree with her religion beliefs. d. Tell her you understand her religious concerns and notify the physician.

Answer: D Rationale: The nurse should tell the client that she understands the client's religious concerns and then notify the physician. The nurse can't administer the transfusion anyway. This violates the client's right of freedom of religion and the right to refuse treatment. The nurse shouldn't pass judgment on the client or refuse to care for a client based on her religion. Source: NCLEX-RN review made incredibly easy 4th edition, page 746.

A nurse manager has been notified to obtain a bed for a client. Of the following clients, which one would the nurse anticipate being able to discharge? a. A client who had a myocardial infarction (MI) 2 days ago. His vital signs are: BP - 150/94, pulse - 84 and irregular, respiratory rate of 28, minimal chest pain b. A client who underwent an abdominal aortic aneurysm resection. His vital signs are: BP - 130/88, pulse - 88, respiratory rate of 22, temperature of 101* F. He is beginning oral intake without problems c. A client who has subdural hematoma. He is lethargic, BP - 150/90, pulse of 60, respiratory rate of 28, and temperature of 99* F. d. A client who had abdominal exploratory surgery for a bowel obstruction 4 days ago. He has bowel sounds, is taking fluids orally, has an abdominal Penrose drain, and is continuing to experience abdominal pain.

Answer: D Rationale: This is the most stable client that could be discharged. Clients in options A and C are showing signs of being unstable with their diagnosis. The client in option B is stable, but because of the extensiveness of his surgery and because he had surgery only 3 days ago, he is less likely candidate to move than the client in option D. Source: Zerwekh, J. & Claborn, J.C. (2006). Illistrated study guide for the NCLEX-RN exam (6th ed.). Philadelphia, P.A.: Mosby Inc. p. 78 and 615

You are a nursing manager in the emergency department. There has been a multi vehicle car accident. When triaging patients, place the patients in order from highest priority to lowest priority. 1. Child with a simple fracture of the arm complaining of arm pain 2. Confused female with bright red blood pulsating from a leg wound 3. Sobbing child with several minor lacerations on the face, arms, and legs 4. Male with closed head wound and multiple compound fractures of the arms and legs. a. 2, 4, 1, 3 b. 3,4, 2,1 c. 4,2, 3, 1 d. 2,1,4,3

Answer:A Rationale: Triage identifies victims of highest priority. Victim 2 has a pulsating wound that indicates arterial puncture, and is also confused which could be indicative of hypoxia. Victim 4 has multiple traumas so is also classified as emergent, but because of arterial puncture in Victim 2 it is not as emergent. Victim 1 has sustained injuries that are not life threatening and can be treated in 1- 2 hours. Victim 3 has sustained minor injuries that can wait several hours for treatment. Saunders comprehension exam review page 75

A 22 year old female arrives to the ED via ambulance after being shot in the left forearm by a neighborhood gang. After primary care by the EMTs, she is now refusing care. After assessment she has been determined to be of no immediate harm to herself or others. Which of the following actions by the nurse would be inappropriate? a. Encourage the patient to accept medical help b. Adhere to the patient's wishes because we cannot treat her without her consent c. Tell the patient that you have notified the police of the gunshot wound d. Call the doctor to admit the patient to the hospital and under a 72 hour hold

Answer:D Rationale: All gunshot wounds must be reported to the police. A 72 hour hold can only be placed on patients that have been assessed to be an immediate harm to themselves or others

1. 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 understands that planning care delivery will be based on which characteristic of this type of nursing model of practice a. A task approach method is used to provide care to clients b. Managed care concepts and tools are used in providing client care c. A single registered nurse is responsible for providing care to a group of clients d. A registered nurse leads nursing personnel in providing care to a group of clients

Answer:D Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option A identifies functional nursing. Option B identifies a component of case management. Option 3 identifies primary nursing (Saunders, 2014).

1. A client newly diagnosed with TB is being admitted with the prescription for "isolation precautions for tuberculosis." The nurse should assign the client to which type of room? a. A room at the end of the hall for privacy. b. A private room to implement contact precautions c. A room near the nurses' station to ensure confidentiality. d. The implementation of contact precautions for possible TB requires a private room assignment.

Answer: A Rationale: According to the centers for disease control (CDC), in addition to isolating the client by using a private room, engineering controls can also help to prevent the spread of TB; a room at the end of the hall will aid controlling the direction of the airflow an can prevent contamination of air in adjacent areas. Airborne precautions, rather than contact precautions, are required to prevent the spread of TB. Confidentiality is provided for every client, regardless of the clients' room location. Source: Nclex-rn review made incredibly easy, published by Wolters Kluwer/Lippincott Williams & Wilkins.

1. Your the charge nurse and one of your UAPs comes to tell you about a situation that made them feel uncomfortable. They tell you that a patient that is post-op day 1 from an abdominal resection requests pain medication; their nurse says, "Again, they are just drug seeking trash and if they are on their phones they obviously don't need pain medication." What action should you do as the charge nurse? a. Take the nurse that made the prejudice statement aside privately to confront them. b. Do nothing c. Only administer the pain medication d. Confront the nurse at the nurses' station

Answer: A Rationale: Failure to intervene can allow the conflict to get out of hand. Confrontation is the most effective means for resolving conflicts and it is best done in private in order to facilitate the desired outcome. pg. 165-167 Effective leadership and Management in Nursing

1. The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage, the nurse should attend to the client with which problem first? a. fractured tibia b. penetrating abdominal injury c. bright red bleeding from a neck wound d. open massive head injury in deep coma

Answer: C Rationale: The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last.

1. The experienced nurse has recently taken a position on a medical unit in a community hospital, but after 1 week on the job, he finds that the staffing is not what was discussed during his employment interview. Which approach would be most appropriate for the nurse to take when attempting to resolve the issue? a. Immediately give a 2-week notice and find a different job. b. Discuss the situation with the manager who interviewed him. c. Talk with the other employees about the staffing situation. d. Tell the charge nurse the staffing is not what was explained to him.

Answer:B Rationale: The nurse should give the manager a chance to discuss the situation before quitting. A temporary problem, such as illness, may be affecting staffing. (#56, Prioritization, Delegation, & Management of Care for the NCLEX-RN exam, 2014).

1. Your floor director wants to implement more EBP into use and to reduce nurse turnover on the floor. Which leadership style would be most effective in completing this task? a. Transactional b. Laize Fair c. Transformational d. Emotional

Answer:C Rationale: Transformational leaders focus on merging motives, desires, values, and goals of leaders and followers into a common cause. Transformations leaders also foster follower's inborn desires to pursue higher values, humanitarian ideals, moral missions, and causes which reduces burnout among employees. pg 43 in Effective leadership and Management in Nursing

3. The nurse preceptor observes the new RN administering medications. The preceptor concludes there is a risk for medication errors when the new RN takes which action? a. Answers a physician's page while giving medications b. Uses military time for documentation c. Asks for help with a dosage calculation d. Does not give a medication that the client questions

Answer: A Rationale: The nurse should never interrupt the medication administration process because this increases the risk of medication errors. (Hogan, 2012. Pg 62)

1. The RN is discharging a 72 year-old client who is 5 days post-operative repair of a fractured hip. The patient verbalizes fear that he is not stable to be alone. What do you do first as the RN? a. Contact a home health agency and set him up with home visits. b. Contact PCP for referral. c. Tell the patient to contact a home health agency d. You as the RN write the order for home health

Answer: B Rationale: You have to have a referral from a PCP to implement referrals. Source: Compressive review for the NCLEX RN reviews and rationales pg. 38

1. A nurse is planning to teach a 75 year old adult how to change a surgical dressing before being discharged from the hospital. What strategy should the nurse use that takes in to consideration the patient's developmental level? a. Incorporate repetition into the teaching plan. b. Obtain a return demonstration of the procedure. c. Include a family member in the teaching session. d. Build on the patient's past positive learning experiences.

Answer: A Rationale: Information processing speed declines with age, slowing learning and increasing the need for repetition (Nugent & Vitale, 2014, p. 202 & 208).

1. The male Mexican American client, who is terminally ill, refuses hospice services because he says it is "giving up" and he is not going to die. Which is the most appropriate action by the nurse? a. Discuss the philosophy and services of palliative care with the client. b. Take no other action and support the client's decision. c. Contact the client's healthcare provider to discuss the prognosis. d. Talk to the client's family members about his choice to refuse hospice.

Answer: A Rationale: The Mexican American families are close-knit communities and often prefer to care for their own family members; therefore, they would not seek hospice or palliative care. The nurse should attempt to help the client understand the philosophy, the benefits, and the help hospice can give the client and family. (Hargrove-Huttel & Colgrove, 2014)