Nclex Review- Mgt of Care

Petechiae Petechiae on the neck and chest often occur with a fat embolism. Clients with long bone fractures are at risk for fat embolism during the first 48 hours after the trauma occurred. Assess and call HCP Oxygen may be necessary, Assess first Assessing pedal pulses and foot warmth is important but unrelated to the present problem. Further assessment is required before requesting a change in pain medication.

A client admitted with a femur fracture 24 hours ago becomes confused. Which would the nurse do first? Assess for petechiae. Administer oxygen. Check for bilateral foot warmth and pedal pulses. Request that the health care provider change the pain medication.

Responsibility Accountability Responsibility and accountability are transferred in this situation because the RN assigns the work to the other RN for the care of the client for an effective outcome.

A client is admitted to the medical unit with pulmonary edema. The registered nurse (RN) admits the client, writes a plan, and assigns the work to another RN. Which factors are transferable in this case? Select all that apply. One, some, or all answers may be correct. Authority Supervision Responsibility Accountability Communication

Phenomenon- A theory contains a set of components such as concepts, definitions, assumptions, or propositions that explain a phenomenon.

A theory contains a set of components such as concepts, definitions, assumptions, or propositions. Which do these components help explain?

Alternative treatment options Risks and benefits of the treatment Risks involved in refusing the treatment Nature of the problem requiring the treatment

Before a treatment requiring informed consent can be performed, which information must the health care team give to the client? Select all that apply. One, some, or all responses may be correct. Cost of the treatment Alternative treatment options Risks and benefits of the treatment Risks involved in refusing the treatment Nature of the problem requiring the treatment

"A successful manager should take risks." "A successful manager should tolerate uncertainty." "A successful manager should experiment with ideas for a unique situation."

During an interview for the position of manager in health care, the candidate is asked about the important qualities of a successful manager. Which responses would be appropriate? Select all that apply. "A successful manager should take risks." "A successful manager should tolerate uncertainty." "A successful manager should show willingness to lead and follow peers." "A successful manager should experiment with ideas for a unique situation." "A successful manager should exert power for communication through different channels."

Active hemorrhage Substernal chest pain

For clients with which conditions would the nurse seek immediate care? Select all that apply. One, some, or all responses may be correct. Hip fracture Simple laceration Active hemorrhage Substernal chest pain Closed extremity trauma

"Note the oxygen saturation reading." "Check whether the client is taking fluids." "Ensure that the client has time for uninterrupted sleep."

In the health care unit, there are 30 clients and the charge nurse delegates client care to the care team. Which statements made by the delegator would indicate care responsibilities are assigned to unlicensed assistive personnel (UAP)? Select all that apply. "Note the oxygen saturation reading." "Administer oral antibiotic medications." "Check whether the client is taking fluids." "Admit the client to the intensive care unit." "Ensure that the client has time for uninterrupted sleep."

Explaining and persuading " selling" - the delegator assigning work to delegatee -explain procedures/techniques leader- guiding/directing "telling," - the delegate simply assigns the task to the delegatee. leader's- observing or monitoring "delegating," -the delegator is responsible and accountable for the entire task. leader- behavior that is encouraging or problem-solving "participating," - the delegator establishes a working environment in which to complete the task in the specified time

The delegator, working in collaboration with a delegatee, assigns responsibilities and explains the various procedures and techniques needed to accomplish the task. Which action is the delegator performing, according to the Hersey model? Guiding and directing Observing or monitoring Explaining and persuading Encouraging or problem-solving

Cultural marginality- situations and feelings of passive betweenness when people exist between two different cultures. Acculturation -adapting to a particular culture. Ethnocentrism refers to the belief that one's own ways are the best, most superior, or preferred ways to act, believe, or behave. Cultural imposition is defined as the tendency of individuals or groups to impose their values, beliefs, and practices on another culture for varied reasons.

The nurse leader states, "The people in rural America dress and act differently from those in urban centers." Which concept describes this statement? Acculturation Ethnocentrism Cultural imposition Cultural marginality

Monitoring clinical manifestations Monitoring clinical manifestations is performed by the unlicensed assistive personnel and the data are reported to the RN.

Which role would the unlicensed assistive personnel (UAP) have when caring for a client receiving intravenous (IV) therapy? Monitoring clinical manifestations Collecting the data to be used in the assessment of the IV site Administering IV fluids and medications Evaluating the client for clinical manifestations

Patient-benefit model-uses substituted judgment The decision model is used for nurses; it depends on specific circumstances to know if the situation is routine and predictable or complex and uncertain. The autonomy model facilitates decision-making for competent clients. The social justice model considers broad social issues and is accountable to the overall institution.

A client with myocardial infarction is brought to the emergency department, and the primary health care provider recommends the placement of a stent. The client is incompetent to understand the situation. Which model would the nurse manager think would be beneficial in this situation? Decision model Autonomy model Social justice model Patient-benefit model

Modeling and challenging in transformational leadership. Modeling - a leader must take an active role in the work of change Challenging - questioning the methods, finding new solutions Inspiring -sharing a vision, bringing everyone together to work toward a goal Enabling others to act includes empowering people to believe that their extra effort will have rewards and will make a difference. Encouraging involves giving attention to personal things that are important to people

According to Kouzes and Posner, which key practices are involved when a leader takes an active role in the work of change and creative thinking about new solutions? Select all that apply. One, some, or all responses may be correct. Inspiring Enabling Modeling Correct answer Challenging Encouraging

Implement seizure precautions immediately. The nurse would implement seizure precautions immediately. A lithium level of 2.0 (2.0 mmol/L) or greater- intoxication, s/s: include seizure Crash cart would be the priority if the client's troponin T level was elevated. No indication of a heart attack. With an elevated lithium level, the blood pressure would be monitored for hypotension. A stat finger stick is not the priority. The client's value (2.6) is within the therapeutic range (2.0-4.

After reviewing the laboratory results, which priority action would the nurse take for a client who is taking medications for bipolar disorder, type 2 diabetes, and peripheral vascular disease? INR: 2.6, Troponin T: negative, Lithium 2.5mmol/L, A1c: 8.2% Implement seizure precautions immediately. Move the crash cart outside the client's room. Assess the client's respiratory and temperature status. Perform a stat finger stick to check the blood sugar level.

The client should have been turned regularly.

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods. The family blames the nurses and threatens to sue. Which is considered when determining the source of blame for the pressure ulcer? The client should have been turned regularly. Older clients frequently develop pressure ulcers. The nurse is not responsible to the client's family. Nurses should respect a client's right not to be moved.

Conversion Clients with conversion disorder have physical symptoms caused by unconscious psychological conflicts and stressors. exacerbated by significant psychological stressors. Malingering -manipulation false or exaggerated symptoms are used to obtain a specific result Referred pain originates in one area of the body and is experienced in another Body dysmorphic disorder is when a person believes that his or her body is deformed in some manner that is not readily observed by others.

On which mental health disorder would the nurse focus the plan of care for a client with paralysis of the upper arms in which no physical pathology is identified? Conversion Malingering Referred pain Body dysmorphic disorder

Exploratory -develop or refine dimensions of phenomena or to develop a hypothesis about the relationships among phenomena. Evaluation research focuses on determining the effectiveness of a program, practice, or policy. Descriptive research focuses on measuring the characteristics of people, situations, or groups and the frequency with which certain events or characteristics occur. Correlational research aims to explore variables of interest without any active intervention by the researcher.

The nurse is going through a pilot research study that aims to identify the effectiveness of using an experimental therapeutic communication technique when dealing with aggressive clients. This describes which type of study? Evaluation research Exploratory research Descriptive research Correlational research

The UAP (CCA) elevates the client's affected leg on a pillow. Using a pillow to elevate the affected leg would cause flexion of the hip, which is to be avoided; the nurse would intervene to correct this behavior. Keeping the heels off the bed is an important measure to prevent skin breakdown. The abduction pillow promotes proper position of the prosthesis and helps prevent dislocation. Use of a walker is important to assist with ambulation and promote safety.

The nurse is managing care for a client who has had a total hip arthroplasty. Which action by the unlicensed assistive personnel (UAP) ([continuing care assistant (CCA]) will require the nurse to intervene? The client's heels are kept off the bed. The UAP (CCA) elevates the client's affected leg on a pillow. The UAP (CCA) uses a pillow to keep the client's legs abducted. The client uses a walker when ambulating with the UAP (CCA).

Subcutaneous emphysema on the second postoperative day- evidence of a leak from the chest tube or the lung into the subcutaneous tissue. Clots are expected initially after surgery. Bloody drainage is expected immediately after surgery. Decreased bubbling in the water-seal chamber on the third postoperative day occurs as the lung is reexpanding or if there is an obstruction in the chest tube; bubbling stops completely when the lung is expanded fully.

The nurse is providing postoperative care to a client with cancer of the lung who had a lobectomy. The client has a chest tube attached to suction. Which assessment finding indicates a complication? Clots in the tubing during the first postoperative day Bloody fluid in the drainage-collection chamber on the first postoperative day Subcutaneous emphysema on the second postoperative day Decreased bubbling in the water-seal chamber on the third postoperative day

"I will focus on tasks and activities allotted to me." "I will coordinate the unlicensed personnel to provide care to a large group of clients." functional model -performing tasks and activities that are allotted to her or him. Focusing on one nurse caring for one client -client care delivery. Concentrating on the use of team collaborations -primary nursing of client care delivery. Providing comprehensive and coordinated nursing services indicates the primary nursing model.

The nurse leader is teaching about the functional model of nursing to a student nurse. Which statements made by the student nurse indicate effective learning? Select all that apply. One, some, or all responses may be correct. "I will focus on one nurse caring for one client." "I will accentuate the use of team collaborations." "I will focus on tasks and activities allotted to me." "I will provide comprehensive and coordinated nursing service." "I will coordinate the unlicensed personnel to provide care to a large group of clients."

B

The registered nurse (RN) delegates a task to a licensed practical nurse (LPN). Which client task can be assigned to the LPN? A: Dehydration- Evaluate whether fluid electrolyte needs are being addressed with intravenous therapy. B: Wound Care- Perform sterile dressing changes on acute/chronic wounds C: Pain- Notify the primary HCP if client reports pain D: Presbycusis- Help with hearing aid placement

Suction as needed. The nurse should observe the client's need for tracheal/oral/nasal suctioning every 2 hours and provide adequate suctioning as needed. The nurse should not routinely administer sedatives as frequently as possible; The nurse should turn the client every 2 hours, not 4 hours. The nurse should not adjust vent settings every 2 hours; however, the nurse should check ventilation settings at least once a shift.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? Administer sedatives as frequently as possible. Turn the client every 4 hours. Increase ventilator settings every 2 hours. Suction as needed.

Staff meeting conducted every Tuesday at 1:00 PM Assigned tasks rotated among same category of care providers The functional model of nursing is a method of providing client care -licensed/unlicensed staff performs tasks for a large group of clients. Can appear to be autocratic, the nurse manager can improve the staff's lack of independence- freq staff meetings and rotating assigned tasks The nurse manager should analyze client outcomes. The charge nurse makes out daily assignment sheets.

Which actions indicate that a manager is helping staff adjust to functional nursing? Select all that apply. One, some, or all responses may be correct. Staff meeting conducted every Tuesday at 1:00 PM Charge nurse assigned to analyze client outcomes Staff assigned to make out daily assignments sheet Assigned tasks rotated among same category of care providers Staff nurses assigned to review research studies for evidence-based care

Coordinate all client care activities.

Which activity would the nurse manager prepare to do once client-focused care is implemented in an acute care facility? Train staff to perform phlebotomy. Coordinate all client care activities. Schedule the nursing staff's hours of work. Review tasks with unlicensed assistive personnel (UAP).

Alcohol

Which causative agent is common to both hyperthermia and hypothermia? Alcohol Barbiturates Phenothiazines Cardiovascular disease

Yellow A ferritin level of 3 ng/mL (normal: 10-150 ng/mL) and a hemoglobin level of 5 mg/dL (normal: 13.5-17.5 g/dL)-severe iron deficiency anemia. A client with severe anemia has to undergo rapid treatment to replenish the stores of iron and a yellow tag is given to the client.

Which color triage tag would be appropriate for a client whose blood test results show a ferritin level of 3 ng/mL and a hemoglobin level of 5 mg/dL based on priority? Red Black Green Yellow

Achievement of nursing goals Improvement in client outcomes

Which conditions can be met through the process of delegation? Select all that apply. Achievement of nursing goals Improvement in client outcomes Development of critical judgment skills Understanding the art of delegation Application of delegation decision-making in clinical nursing practice

Stability Stability is the element that creates an integrative process that fosters effective delegation decisions. Ability is the factor that needs to be assessed to determine the level the leaders determine. Liability is each person's responsibility and accountability for his or her individual actions. Ethnicity does not play a role in the process of delegation.

Which element creates an integrative process that fosters effective delegation decisions by the registered nurse (RN)? Ability Liability Stability Ethnicity

Focus on the needs of all residents in a long-term care facility The systems thinking theory would describe the need to focus on all the residents in a long-term care facility. Transformational theory is associated with promoting employee development. Leaders obtain feedback from peers and staff according to the style theory. Organizational behavior modification theory believes in avoiding situations that cause discomfort.

Which example would the nurse consider to be a part of systems thinking theory? Promote employee development Obtain feedback from the followers Focus on the needs of all residents in a long-term care facility Motivate the staff to avoid certain situations that cause discomfort

Predictability of outcomes Complexity of the task to be performed

Which factors would the registered nurse (RN) consider during the decision-to-delegate process? Select all that apply. One, some, or all responses may be correct. Evaluation Nursing judgment Predictability of outcomes Pervasive functions of assessment Complexity of the task to be performed

"You performed that procedure safely and professionally." "Let me demonstrate a more effective way to perform the task."

Which feedback given by the registered nurse (RN) to the delegatee is constructive? Select all that apply. One, some, or all responses may be correct. "Well done. Nice job." "I expected you to do better." "You can do better when you concentrate." "You performed that procedure safely and professionally." "Let me demonstrate a more effective way to perform the task."

Improving family health or well-being Preparing for family transitions later in life Providing assistance in family management of illness conditions Achieving health outcomes related to the family's areas of concern

Which goals of care are associated with the family health system model? Select all that apply. Improving family health or well-being Preparing for family transitions later in life Providing assistance in family management of illness conditions Promoting positive family behaviors to achieve essential tasks Achieving health outcomes related to the family's areas of concern

Offer additional support and temporarily lower expectations. The charge nurse would manage a task by temporarily lowering expectations and providing additional support to UNP who lack competence. This strategy allows the UNP to build on strengths, minimize weaknesses, and gain confidence.

Which intervention would the charge nurse use to manage a task when the unlicensed nursing personnel (UNP) lack competence? Give constructive feedback and assign another task. Maintain open, vocal feedback, and withdraw the UNP from the task. Offer additional support and temporarily lower expectations. Provide accountability to the organization and assign the UNP to undergo training again.

The Blue Cross Blue Shield Association is an example of a private indemnity health insurance provider- Private indemnity health insurance is purchased as a group policy by an employer for its employees or by individuals themselves. Medicare is a federally funded program. Medicaid and State Children's Health Insurance Program are state programs.

Which is an example of private indemnity health insurance? Medicare Medicaid Blue Cross Blue Shield Association State Children's Health Insurance Program

Nurse A examines own beliefs about mental health. Nurse B reads an article about interpreting nonverbal behavior. Nurse C volunteers at a clinic that serves an immigrant population. Nurse E uses a cultural assessment tool to gather client data.

Which nurses are taking actions that contribute to the nursing goal of achieving cultural competence? Select all that apply. One, some, or all responses may be correct. Nurse A examines own beliefs about mental health. Nurse B reads an article about interpreting nonverbal behavior. Nurse C volunteers at a clinic that serves an immigrant population. Nurse E uses a cultural assessment tool to gather client data.

Rewarming the affected area in a water bath at a temperature of 106°F The first nursing intervention for a client with frostbite is to rewarm the affected area in a water bath at a temperature of 106°F to thaw the frozen part. Amputation is necessary if the client develops gangrene or severe compartment syndrome, which would require medical diagnosis. Administering prostaglandin therapy along with ibuprofen decreases tissue damage and is given after rewarming the affected area. Loose, nonad

Which nursing intervention would the nurse perform first when assessing a client with severe frostbite? Preparing to amputate the area affected with frostbite Administering prostaglandin therapy along with ibuprofen Applying loose, nonadherent sterile dressings to the damaged areas Rewarming the affected area in a water bath at a temperature of 106°F

Bismuth subsalicylate, 2 teaspoons after each stool- has adsorbent and demulcent effects; stool will stay in the intestine longer, allow the organism to infect the intestinal mucosa. Diarrheal stools -tested for occult blood to determine whether the upper GI is affected. Oral rehydration therapy is an appropriate intervention because it will replace fluid and electrolyte lost in diarrhea. Acetaminophen should be administered to promote comfort if the child has a fever.

Which orders for a child with diarrhea caused by a Salmonella infection should the nurse question? Stool for occult blood Oral rehydration therapy Bismuth subsalicylate, 2 teaspoons after each stool Acetaminophen, 15 mg/kg for temperature above 101°F (38.3°C)

Shock Inhalation injury Direct cardiac injury The primary survey is done to assess the airway-breathing-circulation to identify potential life-threatening conditions. Shock, inhalation injury, and direct cardiac injury are potential life-threatening conditions that are considered during the primary survey. Assessing ecchymosis and subcutaneous emphysema can be done in the secondary survey as life-saving interventions post-primary survey.

Which potential life-threatening conditions would be considered during the primary survey for a client admitted after a fire accident? Select all that apply. One, some, or all responses may be correct. Shock Ecchymosis Inhalation injury Direct cardiac injury Subcutaneous emphysema

Thinking of the big picture- the nurse understanding the needs of the hospital or focusing on the needs of all residents in a long-term care facility. helps the nurse envision the context of the needs Balancing short-term and long-term objectives -the nurse considering the decision of the client about termination of clinical treatment to have a better-quality outcome.

Which principle of systems thinking theory involves the nurse focusing on the needs of all residents in a long-term care facility? Thinking of the big picture Balancing short-term and long-term objectives Using nonmeasurable data systems Recognizing the dynamic, complex, and interdependent nature of systems

"Is the task legally appropriate to delegate?" "Is the task appropriate to delegate based on institutional policies and procedures?" The right circumstance "Is the environment conducive to completing the task safely?" The right direction and communication "Does the delegator provide clear and concise directions for the task?" The right person "Does the delegatee have the knowledge and experience to perform the specific task safely?"

Which questions would the delegator assess to determine the right task? Select all that apply. One, some, or all responses may be correct. "Is the task legally appropriate to delegate?" "Is the environment conducive to completing the task safely?" Your answer is incorrect "Does the delegator provide clear and concise directions for the task?" "Is the task appropriate to delegate based on institutional policies and procedures?" "Does the delegatee have the knowledge and experience to perform the specific task safely?"

"If a woman is in her first trimester, she may end her pregnancy according to state regulations."

Which statement provided by the nursing student post-teaching needs correction regarding abortion-related issues? "If a woman is in her first trimester, she may end her pregnancy according to state regulations." "In the third trimester when the fetus becomes viable, the state's interest is to protect the fetus." "If the fetus is over 28 weeks old, the state requires viability tests before conducting abortions." "In the second trimester, the state enforces regulation regarding the person performing the abortion and the abortion facility."

A high fever should be reported to the child's health care provider. A fever higher than 101.5°F (38.6°C) must be reported because of the increased risk for sepsis in a child without a spleen (asplenia). Contact sports are a concern in children with enlarged spleens because of the possibility of rupture; A splenectomy will not cure this disorder; β-thalassemia is an inherited disorder of hemoglobin synthesis. The splenectomy was done to decrease the need for blood transfusions.

Which statement would the nurse include when discharging a school-aged child who underwent a splenectomy for beta-thalassemia (Cooley anemia)? The child should avoid participation in contact sports. The hematological problems have been cured by the splenectomy. A high fever should be reported to the child's health care provider. Blood transfusions will be needed more frequently than before the splenectomy.

Willingness relates to the individual's attitude towards the task. Ability to diagnose performance is a core competency of a situational leader.

Which statements are true regarding the framework of delegation related to the Hersey's Situational Leadership Model? Select all that apply. A single factor influences the effectiveness of a leader. Ability relates to the individual's attitude and commitment. Willingness relates to the individual's attitude towards the task. Ability to diagnose performance is a core competency of a situational leader. Willingness is the sole factor that must be assessed to determine the readiness of the follower.

King King- the goal of nursing is to use communication to help the client reestablish a positive adaptation to his or her environment. Peplau- the goal of nursing is to develop an interaction between nurse and client. Nightingale- the goal of nursing is to facilitate the reparative processes of the body by manipulating a client's environment. Benner/Wrubel- the goal of nursing is to focus on a client's need for caring as a means of coping with stressors of illness.

Which theorist(s) suggested that the goal of nursing is to use communication to help clients reestablish a positive adaptation to their environments? King Peplau Nightingale Benner and Wrubel

Medical command physician- focuses on determining the number, acuity, and medical resource needs available for the clients in a disaster event. They are responsible for identifying the need for and calling specialty-trained providers to care for clients in the hospital.

Who undertakes the responsibility of identifying the need for and calling of different specialty-trained providers to care for clients in a disaster?

Down syndrome Chromosomal trisomies such as Down syndrome may be marked by a lower-than-typical level of alpha-fetoprotein. Fetal demise, neural tube defects, and esophageal obstruction typically result in increased levels of alpha-fetoprotein.

With which problem is a low maternal serum alpha-fetoprotein associated? Fetal demise Down syndrome Neural tube defects Esophageal obstruction