NCLEX UNIT 8

A nursing instructor asks a nursing student to describe the standards of care formulated by the American Nurses Association. Which statement by the student indicates an inaccurate description of these statements? 1. "They are specific guidelines." 2. "They define professional practice." 3. "They have some similarity to policies and procedures." 4. "They are authoritative statements that describe a common or acceptable level of client care or performance."

1. "They are specific guidelines."

The nurse has received a 7 am change of shift report on four clients. Which client should the nurse check first? 1. A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count 2. A client admitted with pneumonia 4 days ago, who will be discharged later this morning 3. A client with a head injury sustained 3 days ago who is alert but complaining of a headache 4. A client with diabetic ketoacidosis, admitted 2 days ago, whose blood glucose is 180 mg/dL

1. A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count

A group of nurses are reinforcing instructions on health and safety management to survivors of a hurricane before they leave their temporary shelter and return home. Which instructions should the nurses include? Select all that apply. 1. Boil water for 5 to 10 minutes before drinking. 2. Wash hands with soap and water frequently. 3. Avoid mixing chemicals such as cleaning chemicals. 4. Avoid using any water always, for any use in the aftermath of a disaster. 5. Add 10 to 20 drops of chlorine bleach to a gallon of water before drinking.

1. Boil water for 5 to 10 minutes before drinking. 2. Wash hands with soap and water frequently. 3. Avoid mixing chemicals such as cleaning chemicals. 5. Add 10 to 20 drops of chlorine bleach to a gallon of water before drinking.

5 Rights for Delegation

1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation

The nurse educator determines that a newly hired licensed practical nurse (LPN) in a local hospital demonstrates an accurate understanding of professional liability insurance when which statement is made? 1. "It is very expensive and not necessary." 2. "I should obtain my own malpractice insurance." 3. "The hospital's liability insurance will cover my actions." 4. "The majority of suits are filed against health care providers and the hospital."

2. "I should obtain my own malpractice insurance."

An adult client is brought to the emergency department by ambulance after being hit by a car. The client is unconscious and is in shock. A perforated spleen is suspected, and emergency surgery is required immediately in order to save the client's life. No family members are present. In regard to informed consent for the surgical procedure, the nurse plans to take which best nursing action? 1. Ask the hospital chaplain to sign the consent form. 2. Transport the client to the operating room immediately. 3. Call the nursing supervisor to initiate a court order for the surgical procedure. 4. Call a family member to obtain telephone consent before the surgical procedure.

2. Transport the client to the operating room immediately.

Purposes of nursing leadership vary according to the level of application and include

A. improving the health status of individuals or families B. increasing the effectiveness and level of satisfaction among professional colleagues C. improving the attitudes of citizens and legislators toward the nursing profession and their expectations of it

The nurse shares with a client that violation of a civil law usually results in which type of penalty? Select all that apply. 1. Monetary fine 2. Public service 3. Replacement of property 4. Imprisonment for more than 1 year 5. Monetary fine and imprisonment for less than 1 year

1. Monetary fine 2. Public service 3. Replacement of property

After reviewing the psychosocial implications following a disaster, the nurse is assigned to care for a client who has just witnessed a mass shooting. Upon obtaining subjective information from the client, which actions should the nurse take? Select all that apply. 1. Remain calm and reassuring. 2. Allow the client to remain alone. 3. Convey caring behaviors towards the client. 4. Establish rapport and actively listen to the client. 5. Avoid discussing the disaster so that the client will not be upset.

1. Remain calm and reassuring. 3. Convey caring behaviors towards the client. 4. Establish rapport and actively listen to the client.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency.

1. Decline to sign the will.