Saunders NCLEX Review Ch 8
8.32. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? 1. A client requiring a colostomy irrigation. 2. A client receiving continuous tube feedings. 3. A client who requires urine specimen collections. 4. A client with difficulty swallowing food and fluids.
Answer: 3 Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires urine specimen collections. The UAP is skilled in this procedure. Colostomy irrigations and tube feeding are not performed by unlicensed personnel. The client with difficulty swallowing foods and fluids is at risk for aspiration. Test-Taking Strategy: Note the strategic words most appropriate, and note the subject, an assignment to the UAP. Eliminate option 4 first because of the words difficulty swallowing. Next eliminate options 1 and 2 because they are comparable or alike and are both invasive procedures. References: Saunders, p. 79
8.29. A nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory. 2. A client who is schedule for physical therapy at 1 PM 3. A client with a fever who is diaphoretic and restless 4. A postoperative client who has just received pain medication
Answer: 3 Rationale: The nurse should plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. Waiting for pain medication to take effect before providing care to the postoperative client is best. Test-Taking Strategy: Note the strategic word first and use principles related to prioritizing. Nothing the words diaphoretic and restless will assist in directing you to this option. Reference: Saunders, p. 78
8.31. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP? 1. Ignore the resistance. 2. Exert coercion on the UAP. 3. Provide a positive reward system for the UAP. 4. Confront the UAP to encourage verbalization of feelings regarding the change.
Answer: 4 Rationale: Confrontation is an important strategy to meet resistance head on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings. Identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance, but will not address the concern specifically. Test-Taking Strategy: Note the strategic word best. Options 1 and 2 can be eliminated first because of the words ignore option 1 and coercion in option 2. From the remaining options, select the correct option over option 3 because the correct option specifically addresses problem-solving measures. References: Saunders, p. 79
8.27. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and malaise. 2. A client who twisted her ankle when she fell while rollerblading. 3. A client with a minor laceration on the index finger sustained while cutting an eggplant. 4. A client with chest pain who states that he just ate a pizza that was made with very spicy sauce.
Answer: 4. Rationale: In an emergency department, triage involves brief client assessment to classify clients according to their needs for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the types of resources available govern the process. clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limp amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority. Reference: Saunders, p. 78
8.26. The nurse is assigned to care for four clients. In planning clients rounds, which client should the nurse assess first? 1. A client scheduled for a chest x-ray. 2. A client requiring daily dressing changes. 3. A postoperative client preparing for discharge. 4. A client receiving nasal oxygen who had difficulty breathing during the previous shift.
Answer: 4. Rationale: Airway is always the highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities. Test-Taking Strategy: Note the strategic word first. Use Maslow's Hierarchy of Needs theory and the ABCs - airway, breathing, and circulation - to answer the question. Remember airway is always the highest priority. This will direct you to the correct option. Reference: Saunders, p. 78
8.33. A new unit nurse manage is holding her first staff meeting. The manager greets the staff and comments that she has been employed to bring about quality and improvement. The manager provides a plan that she developed and a list of tasks and activities for which each staff memeber must volunteer to perform. In addition, she instructs staff members to report problems directly to her. What type of leader and manager approach do the new manager's characteristics suggest? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire
Answer: 1 Rationale: The autocratic leader is focused, maintains strong control, makes decisions, and addresses all problems. The autocrat dominates the group and commands, rather than seeks suggestions or input. In this situation, the manager addresses a problem (quality improvement) with the staff, designs a plan without input, and wants all problems reported directly back to her. A situational leader will use a combination of styles, depending on the needs of the group and the tasks to be achieved. The sitatuional leader would work with the group to validate that the information that the leader gained as a new employee was accurate and that a problem existed. Then, the leader would take the time to get to know the group and determine which approach to change (if needed) would work hest according to the needs of the group and the nature and substance of the change that was required. A democratic leader is participative and would likely meet with each staff person invidivually to determine the staff member's perception of the problem. The democratic leader would also speak with the staff about any issues and ask the staff for input with developing a plan. A laissez-faire leader is passive and nondirective. The laissez-faire leader would state what the problem was and inform the staff that the staff needed to come up with a plan to "fix it." Test-Taking Strategy: Focus on the subject, the leader and manager approach. Note the data in the question and the words provides a plan that she developed, each staff memeber must volunteer to perform, and instructs staff members to report any problems directly to her. Remember that autocratic managers take control and dominate. References: Saunders, p. 79
8.28. A nursing graduate is attending an agency orientation regarding the nursing model or pracitce 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? 1. The task approach method is used to provide care to clients. 2. Managed care concepts and tools are used in providing client care. 3. A single registered nurse is responsible for providing care to a group of clients. 4. A registered nurse leads nursing personnel in providing care to a group of clients.
Answer: 4 Rationale: In team nursing, nursing personnel are lef by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of care management. Option 3 identifies primary nursing (relationship-based practice). Test-Taking Strategy: Focus on the subject, team nursing. Keep this subject in mind and select the option that best describes a team approach. The correct option is the only one that identifies the concept of a team approach. References: Saunders, p. 78
8.30. The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another client is in pain and needs pain medication. which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the UAP to find out when the last pain medication was given to the client. 3. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other clients.
Answer: 4 Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP. Test-Taking Strategy: Note the strategic words most appropriate and use principles related to priorities of care. Options 1 and 3 delay the administration of pain medication, and option 2 is not a responsibility of the unlicensed assistive personnel. The most appropriate action is to plan to administer the medication. References: Saunders, p. 79
8.34. The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and three unlicensed assistive personnel (UAP) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? 1. A client who requires a bed bath. 2. An older client who requires frequent ambulation. 3. A client who requires hourly vital sign measurements. 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours.
Answer: 4 Rationale: When delegating nursing assignments, the nurse needs to consider skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by the unlicensed assistive personnel (UAP). The licensed practical (vocational) nurse is skilled in wound irrgations and dressing changes and most appropriately would be assigned to the client who needs this care. Test-Taking Strategy: Focus on the subject, assignment to a licensed practical/vocational nurse, and note the strategic words most appropriately. Recall that education and job position as described by the nurse practice act and employee guidelines need to be considered when delegating activities and making assignments. Options 1, 2, and 3 can be eliminated because they are noninvasive tasks that the UAP can perform. References: Saunders, p. 79
8.35. The nurse should use which guideline(s) to plan delegation and assignment-making activities. Select all that apply. 1. Ensuring client safety. 2. Requests from the staff. 3. The clustering of rooms on the unit. 4. The number of anticipated client discharges. 5. Client needs and workers' needs and abilities.
Answer: 1, 5 Rationale: There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delgated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee, and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guielines to use when delegating and planning assignments. Test-Taking Strategy: Focus on the subject, guidelines to use when delegating and planning assignments. Read each option carefully and use Maslow's Hierarchy of Needs theory, note that the correct options directly relate to the client safety. References: Saunders, p. 80
