BMS Kaplan Final Review
Which assignment is most appropriate for the psychiatric nurse who is reassigned to the emergency department? a.) an adult client being admitted for suicidal thoughts b.) a pediatric client with diagnosed with a fractured ulna c.) an adult client demonstrating weakness on the right side d.) an adult client being admitted for chest pain
a
4 clients in the emergency department are reporting adverse effects from their medications. Which client does the nurse see first? a.) the client receiving clozapine and experiencing flu-like symptoms b.) the client receiving valproic acid and experiencing tremors c.) the client receiving lorazepam and experiencing abdominal discomfort d.) the client receiving methylphenidate who lost 5 lb in 4 weeks
a
4 passengers in a motor vehicle accident are transported to the emergency department following an accident. The nurse triages in the emergency department. Which client does the nurse see first? a.) an older adult with a head laceration who is drowsy and speaking incoherently b.) an adult who reports feeling anxious and having palpitations c.) an adult with a laceration to the left leg and numbness of the left foot d.) an older adult with bruising across the chest who was wearing a seat belt on the passenger side
a
Clients from a plane crash are transferred to the hospital. The nurse performs triage in the emergency department. Which client should the nurse see first? a.) the older adult client with a fractured pelvis and bilateral femur fractures; client is not breathing and unresponsive b.) the young adult client with burns to the chest and face area; the client is responsive to stimuli and the client's airway is patent c.) the school-age client with an elbow dislocation; the client is conversing with parents and staff appropriately d.) the preschool-age client with a hip dislocation; the client is crying loudly although is temporarily distractable
b
The nurse plans to delegate tasks to the UAP. Which task is within the UAP's scope of practice and appropriate for the nurse to delegate? (select all that apply) a.) obtain vital signs and document in the client's medical record b.) feed the client and assess the risk for aspiration c.) assist the client with bathing and grooming d.) appropriately document the client's I&O e.) perform a sterile dressing change on a central venous line f.) ensure the client takes all medication as scheduled
a, c, d
4 clients from a house fire are transferred to the ED. Which client does the nurse see first? a.) the client reporting anxiety and palpitations b.) the client with full thickness burns to the face and chest area c.) the client diagnosed with a fracture of the right hip d.) the client with a superficial partial thickness burn to the hands
b
The nurse provides care for clients in a gynecological clinic. Which client does the nurse see first? a.) a middle-age client reporting a dry vaginal wall and painful intercourse b.) an adult client who had a hysterosalpingogram and is experiencing tachycardia and has a generalized rash c.) an adult client preparing for a cervical biopsy who reports feeling highly anxious d.) a young adult client scheduled for a Pap smear who reports heavy bleeding with menstruation
b
The nurse reviews a client's medical record. The nurse understands which document entry is an example of objective data? a.) "client reports, 'I feel so anxious'" b.) "skin of left leg is pale, cool, and dry" c.) "client reports pain in left leg which worsens with movement" d.) "client is anxious and defensive"
b
The nursing team caring for clients on the pediatric unit consists of 2 nurses, 2 LPN/LVNs, and 2 UAP. Which client does the nurse assign to the LPN/LVN? a.) the client admitted with asthma b.) the client in a balanced suspension traction for a fractured left femur c.) the client admitted for intestinal bleeding d.) the client admitted for ingesting a grandparent's anti-hypertensive medication
b
The nursing team consists of 2 nurses, 1 LPN/LVN, and 2 UAPs. The nurse considers which assignment appropriate for the LPN/LVN to complete? a.) obtain vital signs for the client immediately after ECT b.) assist the client with bathing and feeding c.) administer a tube feeding for the client with dysphagia d.) discharge the client diagnosed with multiple sclerosis e.) teach the client how to administer a subcutaneous injection f.) change the clean dressing for a client with a venous ulcer
c, f
The nursing team consists of the nurse, 2 LPN/LVNs, and 2 UAP. It is most appropriate for the nurse to care for which client? a.) a client with right-sided weakness requiring assistance with morning care b.) a client requiring administration of digoxin and furosemide via an NG tube c.) a client whose adult child is upset because the client is diagnosed with terminal cancer d.) a client who is 24 hours after a laminectomy with spinal fusion and is having difficulty voiding
d
The nursing team on the pediatric unit consists of 1 RN, 1 LPN/LVN, and 2 UAPs. Which client does the nurse assign to the LPN/LVN? a.) the client admitted with vomiting, weight loss, and abdominal pain b.) the client admitted with decreased hemoglobin and hematocrit reporting fatigue c.) the client diagnosed with a UTI who requires discharge instructions d.) the infant client requiring antibiotic ointment on the circumcision site
d
The home health nurse is concerned about the large number of clients who are receiving home visits even though they no longer need skilled nursing or therapy services. The nurse discusses these concerns with the management of the agency, but no changes are made. Which would protect the nurse from termination if the nurse reports the agency to regulatory authorities? a.) Title VII of the Civil Rights Act of 1964 b.) Whistleblower Laws c.) Occupational Health and Safety Act d.) Family and Medical Leave Act
b
The nurse manager is hired for the pediatric unit. The nurse manager state in a meeting, "I run my unit with a lot of control and make all the decisions." The staff recognizes the nurse manager is practicing which leadership style? a.) autocratic b.) laissez-faire c.) democratic d.) situational
a
The new graduate registered nurse is assigned a preceptor on the medical surgical unit. Which staff member is more appropriate to serve as the new graduate's preceptor? a.) the nurse manager for the medical surgical unit b.) a staff registered nurse with 4 years of experience on the medical surgical unit c.) a LPN/LVN with 8 years of experience on the medical surgical unit d.) a registered nurse with 20 years experience reassigned from the pediatric floor
b
The community health nurse plans visits for the day. Which client does the nurse see first? a.) the client diagnosed with type 2 diabetes reporting GI upset after taking chlorpropamide b.) the client reporting vomiting after chemotherapy c.) the client with a tonometer reading of 21 mmHg d.) the client with a laryngectomy reporting a greenish-yellow discharge
d
The nurse manager observes the response of several staff to change that occurs on the medical surgical unit. The staff are classified as "early adopters" if which behavioral patterns are observed? a.) the staff are open and receptive to new ideas and are sought out by others b.) the staff thrive on change and see it as an exciting adventure which can advance their careers c.) the staff are not the first to accept a change, nor are they the last d.) the staff are openly negative about changes and adopt them only after most others have done so
a
The nurse manager talks with staff about conducting peer review for documentation of client care. Which nurse will conduct a peer review of the staff nurse? a.) another staff nurse on the unit b.) the nurse educator c.) a nurse manager from another unit d.) the facility risk manager
a
The nurse manager wants to implement a 3-day workweek on the nursing schedule. The nurse manager states, "Anyone who agrees to a 3 day schedule will receive an increase in the hourly rate of pay." The nurse manager is demonstrating which type of power? a.) reward power b.) coercive power c.) expert power d.) referent power
a
A client diagnosed with stroke is admitted. The nurse notes the client has difficulty swallowing and requires assistance with bathing, toileting, and feeding. The delegation is appropriate if the nurse delegates the tasks of bathing and toileting to which staff member? a.) the UAP b.) the LPN/LVN c.) the speech therapist d.) the respiratory therapist
a
A client's spouse on the medical surgical unit states to the day shift nurse, "My spouse was wakened all night long by the staff talking and laughing at the nurses' station. I demand to speak to the chief nursing officer." which action by the nurse is most appropriate? a.) apologize to the client's spouse and report the situation to the nurse's immediate supervisor b.) inform the spouse the night shift will be reprimanded and the situation will not occur again c.) inform the spouse that this situation is not something that is addressed by the chief nursing officer d.) contact the chief nursing officer immediately to report the situation and complete an incident report
a
A medical surgical unit uses the team nursing model of care to provide client care. Which description most accurately describes team nursing? a.) the nurse leader is responsible for coordinating a group of licensed and unlicensed personnel to provide client care b.) the staff members perform specific tasks for a large group of clients c.) one nurse is responsible for the client's total care throughout the client's hospitalization d.) a team of staff members is assigned to a specific area of the nursing unit and cares for clients in that area
a
An older adult client asks the nurse what caused the client's cataract. The nurse's response is based on which information? a.) cataracts are most common in the older adult b.) the usual cause of cataracts in older people is congenital c.) cataracts commonly develop when a client has any type of chronic systemic disease d.) the most common cause of cataract is injury to the eye
a
An older adult client is diagnosed with otosclerosis. Which symptoms does the nurse expect the client to have? a.) hearing loss and buzzing ear noise b.) headache and vertigo c.) pain and ringing in the ear d.) progressive deafness and excessive cerumen
a
The charge nurse is having difficulty making an appropriate assignment for the nursing team. Which assessment by the supervisor helps the charge nurse make the assignment for the day shift? a.) "describe the knowledge and skill level of each member of your team" b.) "do you know which assignment each staff member prefers?" c.) "how long has each staff member been employed on the unit?" d.) "do you know if any staff members are working overtime today?"
a
The nurse cares for a client with a managed care plan of insurance. Which is correct about managed care? a.) the client may only use certain approved providers b.) the client has unlimited coverage for all services prescribed c.) the client may have services without prior authorization d.) the client may select any provider the client desires to provide care
a
The nurse enters the room of a client admitted for evaluation of a convulsive disorder. The family members present report the client just had a seizure. After determining vital signs are normal and there are no injuries, then placing the client in side-lying position, which action does the nurse take next? a.) interviews the family about what they observed, including duration of the seizure, and accurately documents their responses using their own words b.) explores the feelings of the family regarding witnessing the seizure activity now and in the past c.) documents that the family witnessed a seizure but the nurse did not, and records the vital signs of the client d.) instructs the family to call the nurse the next time, completes an incident report, and notifies the health care provider
a
The nurse has assessed clients on the psychiatric unit. Which activity is appropriate for the nurse to delegate to the UAP on a psychiatric unit? a.) perform 30-min checks on each client b.) obtain lithium level on a client who may be toxic c.) lead a group on anger management with 8 clients d.) administer fluoxetine to a client as prescribed
a
The nurse is assigned to prioritize the care for clients in the psychiatric clinic. Which client does the nurse see first? a.) the adolescent client who was brought in by the police threatening to jump off a bridge and has access to a gun b.) the young adult client who lost 2 lb this week eating only 2 meals a day c.) the middle aged adult client with a history of depression who is out of fluoxetine d.) the older adult client whose spouse died 2 weeks ago and is experiencing insomnia and irritability
a
The nurse is recently employed in a medical-surgical unit at a medical center which has a clinical ladder system. The nurse understands which statement is accurate about a clinical ladder? a.) a clinical ladder provides a reward system for clinical excellence, with different responsibilities and advantages for each progressive level b.) a clinical ladder is a set of national guidelines and standards used to meet the needs of high acuity level clients c.) a clinical ladder provides each client with a customized step-by-step approach to managing illness d.) a clinical ladder provides a structure to enable a nurse to progress toward becoming a physician
a
The nurse on the medical-surgical unit talks with a client about an advance directive. Which response by the client indicates the client understands the information? a.) "When I complete my advance directive, I need to be sure there is a copy available to my health care provider and health care proxy." b.) "The person I select for my durable power of attorney cannot have any legal or financial attachments to me." c.) "The decisions on my advance directives can not be changed as long as I am still able to communicate my wishes." d.) "After my death, the durable power of attorney can determine my funeral arrangements and handle my finances."
a
The nurse plans assignments for the day after receiving the night shift's report. Which client does the nurse see first? a.) an adolescent client who took 100 mg methylphenidate an has a BP of 160/100 b.) a young adult client who requires a metered-dose inhaler c.) a young adult client with a short arm cast on the left arm d.) a middle-age client diagnosed with hypothyroidism requiring a TSH level
a
The nurse provides care for clients in the child psychiatric clinic. Which client does the nurse see first? a.) the client with auditory hallucinations b.) the client expressing worry about leaving the parent to go to school c.) the client receiving haloperidol experiencing blurry vision and dry mouth d.) the client with a lithium level of 0.8 mEq/L
a
The nurse provides care for clients in the psychiatric emergency department. Which client does the nurse see first? a.) the client receiving haloperidol and experiencing prolonged upward deviation of the eyes b.) the client receiving thioridazine and reporting a need to pace back and forth and an inability to sit still c.) the client receiving risperidone and reporting blurry vision, upset stomach, and dry mouth d.) the client receiving fluphenazine and experiencing sedation, loss of appetite, and depression
a
The nurse received report on four clients in the medical-surgical unit. Based on the report received, which client does the nurse prioritize to see first? a.) the client diagnosed with heart failure who received 800 mL of IV fluids in 2 hours b.) the client diagnosed with lung cancer who has a blood calcium level of 12.5 mg/dL c.) the client diagnosed with hypertension, whose current blood pressure is 162/84 and requires a dose of captopril d.) the client who is postoperative after a laminectomy and requesting to get out of bed for the first time
a
The nurse sees clients in the pediatric clinic. Which client does the nurse see first? a.) an infant client with failure to gain weight and a blood lead level of 70 mcg/dL b.) preschool client who fears body mutilation c.) a school-age client who has repeated involuntary urination at night d.) a school-age client with a persistent fear of attending school
a
The nurse understands the primary purpose of performing a myringotomy on a client with acute otitis media is to achieve which effect? a.) relieve pressure on the eardrum b.) create a pathway for administering medications c.) avert the need for analgesia d.) remove debris from the outer ear
a
The nursing team caring for clients on the pediatric unit consists of one nurse, 2 LPN/LVNs, and 3 UAPs. Which client does the nurse assign to the UAP? a.) the client who needs help socializing with other children b.) the client requiring an 0800 insulin injection c.) the client requiring calcium disodium edetate for elevated lead level d.) the client reporting abdominal tenderness in the right lower quadrant
a
The nursing team consists of 2 nurses, 2 LPN/LVNs, and 2 UAPs. The nurse considers the assignment appropriate if an LPN/LVN is required to complete with task? a.) perform a sterile dressing change b.) obtain vital signs c.) stock supplies of syringes and dressings d.) transfer a stable client to x-ray
a
The nursing team consists of 2 nurses, 2 LPN/LVNs, and 2 UAPs. Which client does the nurse assign to the UAP? a.) assist an older adult client with lunch b.) administer famotidine to a client at 0800 c.) change a dressing for a postoperative client d.) instruct a client about signs and symptoms of lithium toxicity
a
The psychiatric nurse is presented with a group of clients in the emergency department. Which client requires immediate attention? a.) a young adult client who failed medical school and says, "My pain will be over soon." b.) an adult client who is unable to talk in front of other people due to symptoms of anxiety c.) a middle-age client who hears voices saying to harm others d.) a middle-age client who is anxious after witnessing a murder
a
When communicating with an older adult client with a documented hearing impairment, it is most important for the nurse to take which action? a.) speak using hands, face, and eyes b.) speak normally c.) place the client in good lighting so the nurse's mouth can be seen d.) ask the client to write what is said to verify understanding of the message
a
Which change strategy is most likely to be used by nurse managers who believe that people are rational and will act in ways that will be in their own best interest? a.) Empirical-Rational Strategies b.) Power-Coercive Strategies c.) Normative-Reeducative Strategies d.) Historical-Futuristic Strategies
a
The RN assesses clients for the day shift. The nursing team includes 1 RN, 2 LPN/LVNs, and 4 UAPs. The nurse determines assignments are appropriate if which client is assigned to the UAP? a.) the client diagnosed with Crohn's disease requiring a sterile dressing change b.) the client diagnosed with chronic kidney failure requiring intake and output c.) the client diagnosed with full thickness burns requiring IV morphine prior to a dressing change d.) the client diagnosed with cancer of the lung reporting a headache
b
The UAP would question which instruction from the nurse on the maternity unit? a.) ambulate the client 24 hours after the birth of the child b.) administer acetaminophen for pain to the client who has an episiotomy c.) assist the client with morning care d.) give the client pads for vaginal bleeding
b
The charge nurse supervises care of clients on the medical/surgical unit. The charge nurse determines care is appropriate if which task is delegated to the UAP? a.) the client diagnosed with an ulcer requires the morning dose of famotidine b.) the client diagnosed with COPD needs vital signs taken c.) the client diagnosed with diabetes type 2 requiring discharge instructions d.) the client on the day of surgery requiring a sterile dressing change
b
The nurse reviews 10 medical record on the medical unit. The nurse identifies which action is appropriate? a.) failure to obtain informed consent from the other client b.) failure to document in the client's medical record c.) failure to record changes in the client's condition d.) failure to document that an incident report was completed
d
A client in an outpatient psychiatric clinic tells the nurse, "I'm going to kill my spouse. That will make my life much better." Which mandate must the nurse follow to meet legal nursing responsibility in this scenario? a.) good samaritan b.) duty to warn c.) confidentiality d.) advocacy
b
A client with an eye injury to the left eye wears a patch over the injured eye. The nurse identifies which chief visual disturbance the client will experience while wearing the eye patch? a.) inability to focus on very near or far away objects b.) difficulty judging the distance of objects c.) impaired accommodation to darkness d.) floating spots seen in the affected eye
b
A news reporter wants to take a picture of a movie start on the medical/surgical unit. Which action by the nurse is most appropriate? a.) take the picture for the news reporter b.) call the nurse manager c.) contact the police d.) report the incident to the client's healthcare provider
b
Children from a school bus accident are transferred to the hospital. The nurse performs triage in the emergency department (ED). Which child client does the nurse see first? a.) the client with a superficial burn to the arm b.) the client with deep partial thickness burns on 10% of the total body surface area c.) the client with small lacerations to the arms and legs d.) the client reporting severe elbow pain
b
In an effort to heighten staff awareness about group process and their participation in it, the nurse manager plans an inservice focused on the roles people take in groups. Which of the following should be described as the function of the role coordinator? a.) the coordinator arranges the room and furniture, distributes handouts, operates audiovisual equipment, and obtains what is needed b.) the coordinator clarifies relationships between various ideas or suggestions c.) the coordinator relieves tension in conflict situations between group members d.) the coordinator observes the group process and gives evaluative interpretations of dynamics in the group
b
The nurse conducts a preoperative assessment of an adult client admitted to the medical-surgical unit. When the nurse asks if the client has a durable power of attorney, the client states, "Yes, I already have an attorney who helps me with finances." Which is the best response by the nurse? a.) "That's not the same thing. Your regular legal attorney can't help you with your health care. You need to think about that." b.) "A durable power of attorney is someone you have chosen to make decisions on your behalf if you are unable to make and/or communicate decisions." c.) "It's the same as a health care proxy. I'll leave some information with you and you can read about it." d.) "You don't have to have a durable power of attorney, but it would be a good idea to talk to your family."
b
The nurse describes a new nursing vice president's style of leadership. The nurse states, "The vice president lets us do what we want." The nurse is describing which leadership style? a.) autocratic b.) laissez-faire c.) democratic d.) situational
b
The nurse discusses delegation with a new nurse. Which statement by the new nurse indicates an understanding of the meaning of delegation? a.) "delegation means that the nurse is able to accept responsibility for the nursing actions and results" b.) "delegation occurs when the nurse assigns a specific function or aspect of client care to a LPN/LVN or UAP" c.) "delegation occurs when the nurse assigns a task the nurse does not have time to complete to another staff member" d.) "delegation means being obligated to accomplish the assigned work"
b
The nurse educator has just reviewed the concepts of group process roles with a group of nurse managers. One of the managers asks, "Could you please explain what exactly is meant by the gatekeeper role?" Which response by the educator is best? a.) "the gatekeeper decides who is to attend a meeting and who is not" b.) "the gatekeeper ensures that everyone has an opportunity to speak" c.) "the gatekeeper makes certain that the group starts and ends on time" d.) "the gatekeeper responds to interruptions from outside forces"
b
The nurse identifies which as the proper technique for eyedrop administration? a.) instruct the client to look down, retract the lower eyelid, and instill drops b.) instruct the client to look up, retract the lower eyelid, and instill drops c.) instruct the client to look down, retract the lower eyelid, and instill drops, then apply pressure d.) instruct the client to look sideways, and instill the drops in the inner canthus
b
The nurse manager of a medical surgical unit discusses the number of staff that have called out sick during the last time period. The manager states, "I am keeping track of who is calling out. If you call out more than once a month, you will not receive the vacation days you requested." The nurse manager is using which type of power? a.) reward b.) coercive c.) personal d.) referent
b
The nurse manager of a psychiatric day hospital is reviewing group theory as part of the orientation of new nursing staff who are going to develop and lead groups of clients. The manager identifies which group process stage as the one in which members are most likely to engage in arguments and power struggles? a.) forming b.) storming c.) norming d.) performing
b
The nurse observes a new graduate nurse administer an IM injection. The nurse must intervene if which is observed? a.) the new nurse uses a one-handed scoop technique to place the cap on the needle after the injection b.) the new nurse recaps the needle and snaps the needle from the hub before disposing of it c.) the new nurse places the needle cap on a horizontal surface and slides the used needle into the cap d.) the new nurse immediately places the used needle and syringe in a puncture free sharps container
b
The nursing team consists of 2 nurses, 2 LPN/LVNs, and 2 unlicensed assistive personnel (UAP). Which client assigned to the LPN/LVN does the LPN/LVN question? a.) the infant client requiring a bath prior to discharge b.) the infant client with a palpable olive-shaped mass in the epigastrium and frequent vomiting c.) the infant client requiring eye drops instilled d.) the infant client requiring a rectal temperature taken every 6 hours
b
Which intervention does the nurse include in the plan of care for the client diagnosed with an acute attack Meniere disease? a.) encouraging frequent independent ambulation b.) medications and fluids to be given intravenously c.) a diet low in sodium but high in caffeine d.) frequent ear irrigations
b
10 clients from a motor vehicle accident are transferred to the hospital. The nurse triages in the ED. Which client does the nurse see first? a.) a client with ecchymosis and lacerations to the facial area b.) a client who reports chest tightness and pressure c.) a client with a BP of 90/60 mmHg and apical pulse of 120 beats/min d.) a client who reports dizziness and nervousness
c
The nurse sees clients in the pediatric clinic. Which client does the nurse see first? a.) the 5-year-old client diagnosed with autistic disorder demonstrating finger flapping b.) the 6-year-old client who has enuresis and often urinates in the underwear c.) the 7-year-old client who is shy and has difficulty reading d.) the 9-year-old client who used a weapon against the parents and caused physical harm to others
d
A nurse manager terminates a nurse for falsifying an entry in a medical record. Several months later, the manager receives a call from an agency asking for a reference for the terminated employee. Which is the nurse manager's most appropriate response to the potential employee? a.) "I will have to consult an attorney before speaking with you" b.) "the nurse did a good job and then resigned" c.) "that employee did work for me and was terminated for poor performance d.) "I can't speak with you about that employee"
c
An older adult client who is diagnosed with a terminal illness decides to go home with home hospice care. That client's adult child states, "You need to tell the health care provider that we want all possible treatments done." The nurse states, "Your parent is competent and has the right to choose the treatment desired." The nurse's statement is based on which ethical concept? a.) beneficence b.) veracity c.) autonomy d.) nonmaleficence
c
The community health maternity nurse plans visits for the day. Which client does the nurse see first? a.) the newborn client who had an Apgar score of 8 and 9 b.) the newborn client with telangiectatic nevi c.) the newborn client with pallor d.) the newborn client with a blood glucose of 60 mg/dL
c
The community health nurse plans visits for the day. Which client does the nurse see first? a.) the preschool client experiencing hyperactivity and impulsively for 2 weeks b.) the school age client who was truant from school for 3 days c.) the adolescent client vomiting every day for the last 3 months d.) the young adult client who drinks alcohol every day and is unable to control the amount of alcohol inhested
c
The nurse describes the nurse manager's style of leadership. The nurse states, "My nurse manager involves us in making decisions about client care." The nurse is describing which leadership style? a.) autocratic b.) laissez-faire c.) democratic d.) situational
c
The nurse from the pediatric unit is assigned to the psychiatric unit. Which client assignment is the most appropriate for the reassigned nurse? a.) a psychotic client who hears the devil saying "Kill yourself." b.) a suicidal client who voices a plan to jump off a bridge today c.) a client diagnosed with depression with a decreased appetite d.) an adolescent who has vomited every day for 3 months
c
The nurse from the psychiatric unit is reassigned to the pediatric unit. Which client assignment is most appropriate for this nurse? a.) a preschool-age client diagnosed with type 1 diabetes admitted with a blood glucose of 370 mg/dL and reporting thirst and frequent urination b.) a school age client diagnosed with hemophilia requiring discharge instructions about appropriate and safe sports c.) a toddler client with a superficial partial thickness burn to the right thigh who cries and screams whenever the parent tries to leave the room d.) an adolescent client with a newly diagnosed brain tumor reporting headaches and left-sided weakness
c
The nurse identifies which environmental factor is most helpful to maintain independence for a client who is legally blind? a.) a radio on the bedside table b.) a nurse call light that is east to reach c.) the furniture in the room consistently arranged d.) a room with a private bathroom
c
The nurse is adopting 2 children and informs the nurse manager of plans to take 4 weeks off. The nurse manager identifies which legal act allows the nurse to take the time off? a.) Age Discrimination Act b.) Americans with Disabilities Act c.) Family and Medical Leave Act d.) Adoptions Leave Act
c
The nurse manager plans to conduct a performance appraisal of a nurse employed on the unit for the last year. To provide an accurate evaluation of the nurse's performance, which action by the nurse manager is most appropriate? a.) talk with other staff member's about the nurse's recent job performance b.) review any disciplinary actions and performance improvement plans the new nurse has received c.) enter anecdotal notes into the nurse's file periodically throughout the year d.) base the performance appraisal on the nurse's most recent skills competency and completed education modules
c
The nurse moves to a different state and reviews the Nurse Practice Act (NPA) for the state. The nurse understands which governing body enforces the rules of the NPA? a.) American Nursing Association (ANA) b.) National Council of State Boards of Nursing (NCSBN) c.) State Board of Nursing (BON) d.) State Nursing Association
c
The nurse must use critical thinking skills while providing care for a client receiving a blood transfusion. Which is the best example of critical thinking in the care of this client? a.) the nurse reviews the procedure for blood administration b.) the nurse checks a unit of blood with another nurse c.) the nurse evaluates changes in the client's vital signs during the procedure d.) the nurse documents the procedure in the medical record
c
The nurse on the pediatric unit receives the night shift's report and plans assignments for the day. Which client does the nurse see first? a.) the client diagnosed with leukemia reporting fatigue b.) the client diagnosed with Wilms tumor reporting thirst c.) the client diagnosed with hemophilia reporting joint pain d.) the client diagnosed with gastroesophageal reflux reporting abdominal pain
c
The nurse overhears the unit secretary tell a joke with sexual overtones to another staff member. The nurse is offended by the sexual nature and language of the joke. Which action does the nurse take first? a.) immediately document the incident b.) immediately report the incident to the supervisor c.) immediately inform the unit secretary that the nurse is offended d.) immediately file a sexual harassment complaint with human resources
c
The nurse prepares a client for discharge from the neurological unit. The client must sleep with the head of the bed elevated 30 degree, and the client cannot afford to buy a hospital bed that can be adjusted with levers or electronic devices. The nurse learns the client's insurance company will also not pay for the bed. Which is the best action for the nurse to take? a.) encourage the client to sleep on the couch with head resting on an armrest b.) tell the client to have blocks placed under the foot of the bed c.) instruct the client to collect or buy several pillows d.) advice the client to awaken every 3 hours and stretch
c
The nurse receives a call from the emergency management team that a bomb exploded on a train. Thirty victims will be transported to the hospital in 10 min. Which action does the nurse take first? a.) inform the emergency management team that 10 clients will be accepted to the unit b.) no action is required. The nurse will prepare to receive the clients c.) contact the nursing supervisor d.) tell the nurses on the shift they will all have to work overtime
c
The nurse sees clients in the adolescent psychiatric clinic. Which client does the nurse see first? a.) the school age client who reports impulsivity and poor attention span b.) the adolescent client who displays frequent loss of temper and argues with teachers c.) the adolescent client who wants to be a model and only drinks water and eats vegetables d.) the adolescent client who bullies, threatens, and intimidates others and frequently initiates physical fights
c
The nurse teaches a client diagnosed with an infection of both the left eye and right eye how to care for the eyes. It is most important for the nurse to include which instruction? a.) touch the eyes with the medication dropper when instilling eye drops b.) put firm pressure on the eyeball when wiping or cleaning the eye c.) clean each eye with a separate tissue to prevent cross-contamination between the eyes d.) wash the hands after completing eye care
c
The pediatric community health nurse plans visits for the day. Which client does the nurse see first? a.) the school age client with a blood lead level of 9 ug/dL b.) the school age client who is aggressive toward siblings when angry c.) the preschool-age client with elevated temperature, cough, and fine crackles d.) the infant client who had a pyloromyotomy 4 weeks ago
c
The student nurse identifies characteristics of good documentation in a client's medical record. Which description adheres to the legal guidelines for appropriate documentation? a.) the nurse leaves blank lines in the nurse's notes so the previous shift can add to the documentation b.) the nurse utilizes correction fluid to erase the mistake made when documenting c.) the nurse documents any changes to the client's condition and any nursing actions taken in response to the recorded changes d.) the nurse documents, "health care provider accidentally ordered incorrect medication," after seeking clarification of the order
c
The nurse understands which is primary focus of the NCLEX-RN? (select all that apply) a.) performance appraisal b.) evaluation of nursing schools c.) assessment of minimum competency d.) determination of ability of entry level nurse to perform safely e.) measurement of quality client care
c, d
After receiving the night shift's report, the nurse prioritizes for the day on the Endocrinology Unit. Which client does the nurse see first? a.) the client requiring a finger stick glucose test prior to breakfast b.) the client requiring a urine test for ketone bodies c.) the client diagnosed with hashimoto thyrioditis being discharged this afternoon d.) the client with a fasting blood glucose of 517 mg/dL on this morning's lab values
d
The day shift nurse gives the change of shift report to the next nurse. The oncoming nurse knows which information is most appropriate for the nurse to include in the change of shift report? a.) the nurse's opinion about the relationship of the client with the spouse b.) a complete description of the routine wound care performed each shift c.) information the nurse heard about the kind of car the client drives d.) how client needs were addressed during the previous shift by the interdisciplinary team
d
The nurse begins employment in a hospital using the SOAP system of documentation. The nurse understands that SOAP is an acronym for which information? a.) strategic, operational, accountability, protocol b.) status, orders, actions, precautions c.) secure, orderly, appropriate, precise d.) subjective, objective, assessment, plan
d
The nurse collapses minutes after putting on latex gloves, and the cardiac team successfully resuscitates the nurse. The nurse manager discusses that certain workers may be at greater risk for latex allergies than others. After reviewing the medical histories of the nurses on the unit, the nurse manager determines which nurse can safely use latex products? a.) a nurse with a history of allergies to pollen and grass b.) a nurse with a history of allergies to bananas and kiwi c.) a nurse with a history of multiple surgeries d.) a nurse with a history of GI upset
d
The nurse completes an incident report when a client falls and is injured, then contacts the risk management department. Which is the primary focus of risk management? a.) educate the client about managing risk factors that would predispose the client to falls b.) teach nurses how to conduct a fall risk assessment c.) ensure all clients at risk for falls are identified at admission d.) prevent and minimize institutional factors that could lead to legal liability
d
The nurse delegates tasks to staff on the night shift. Which task is appropriate for the nurse to delegate to the UAP? a.) begin a blood transfusion on a postoperative client b.) change the colostomy bag on a client with an ileostomy c.) administer morning insulin to a client on a sliding scale d.) obtain a client's daily weight and shift intake and output
d
The nurse educator provides information about negligence during a staff meeting. Which example of negligence does the educator include? a.) the nurse fails to document within 30 min after a change in the client condition b.) a nurse performs a procedure for which the nurse has not been trained or educated c.) a client sues the nurse after the nurse administers an IM injection and causes nerve damage to the client's leg d.) the nurse leaves the confused client alone on the bedside commode to take a phone call, resulting in injury to the client
d
The nurse educator reviews conflict management strategies with new nurse managers. Which strategy does the educator highlight as most likely to be successful when there is conflict among staff? a.) remind staff in conflict of their professionalism and common goal of quality client care b.) refer conflicting parties to policy and procedure manuals and job descriptions c.) explore family-of-origin conflict management experiences of the conflicting staff d.) ask for suggestions for resolution from those involved in the conflict
d
The nurse evaluates clients in the gastrointestinal clinic. Which client does the nurse see first? a.) a middle-age client diagnosed with irritable bowel syndrome reports cramping and loose stools b.) a young adult client reports not having a bowel movement in 2 days c.) a school-age client diagnosed with gastroenteritis who had 5 diarrheal stools in the last 3 days d.) a newborn client experiencing projectile vomiting and irritability
d
The nurse in the outpatient clinic assesses a client diagnosed with mastoiditis. The client reports experiencing chills, fever, nausea, vomiting, and a sore neck. Which action does the nurse take first? a.) encourage the client to take an antipyretic to reduce fever b.) ask if anyone in the client's family is also experiencing the symptoms c.) obtain a list of current medications d.) notify the health care provider
d
The nurse manager holds a staff meeting and discusses substance abuse among nurses. After the meeting, the staff nurse stays behind and asks to speak with the manager about a fellow staff member who could potentially be diverting. The nurse manager suspects this to be true when the staff nurse makes which statement? a.) the staff member changes hair color frequently b.) the staff member is always talkative and loud in group meetings c.) the staff member frequently arrives early for work and uses the computer to gather information on assigned clients, which inconveniences night shift's last minute documenting into client's medical records d.) the staff member frequently does not allow another nurse to visualize narcotics wasted, and states that the waste amount was appropriately disposed in the client's room
d
The nurse notices the client diagnosed with major depression crying in the day room. The nurse puts a hand over the client's shoulder and states, "Let's talk about it." Which ethical principle describes the nurse's action? a.) autonomy b.) veracity c.) nonmaleficence d.) beneficence
d
The nurse observes the student nurse give a presentation about incident reports. The nurse intervenes if the nursing student states which situation requires an incident report? a.) the client has a prescription for citalopram to be administered. The nurse administers clonazepam b.) at 1000 the nurse notes the client's BP is 80/50 and pulse is 110 bpm. Health care provider notified at 1300 c.) the client falls while ambulating to the bathroom and reports right hip pain d.) the health care provider orders digoxin to be administered at 0900. The nurse administers the mediation at 0920
d
The nurse receives a report and assesses the clients on the unit. It is most appropriate for the nurse to assign which client to the LPN/LVN? a.) the client newly admitted with a diagnosis of myocardial infarction, recovering from a heart catheterization b.) the client with a diagnosis of heart failure who also expresses frequent suicidal thoughts c.) the client diagnosed with full-thickness burns covering 40% of the body d.) the client diagnosed with COPD who requires ambulation twice during the evening
d
The nurse receives the assignment for the day shift. Which client is appropriate for the nurse to delegate to the LPN/LVN with 30 years of experience? a.) the adult client reporting chest pain and dyspnea b.) the pediatric client with an abdominal mass that is firm and deep and confined to one side c.) the pediatric client reporting polyuria and polydipsia d.) the adult client 3 days postoperative requiring a dressing change
d
