NCLEX-Leadership

The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources for an effective discharge plan? 1. Primary healthcare provider 2. Case manager 3. Physical therapist 4. Occupational therapist

2. Correct: The client's case manager should be contacted regarding the order for pending discharge from the healthcare facility. The case manager coordinates care and provides the client with information and resources for an individualized discharge plan

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best to assign to the LPN/VN? 1. Identify and assess each incoming client. 2. Triage and assign color-coded tags to each client. 3. Gather and apply dressings to open wounds. 4. Initiate oxygen and IV lines as needed.

3. Correct: An LPN/VN's scope of practice includes tasks such as wound care. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Encourage client to express grief related to loss of independence. 2. Irrigate a client's ear canal. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 4. Show client who has conjunctivitis how to clean the eyes.

3. Correct: Disconnecting NG tube suction is an appropriate task for the UAP.

What clients could safely be delegated to the LPN/VN? Select all that apply 1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction.

1, 2, 5 & 6. Correct: Thes clients are appropriate and stable enough for the LPN/VN's scope of practice. While an LPN/VN cannot be assigned a fresh post-op, the first client had an appendectomy two days ago. The LPN/VN could even delegate ambulating this client to unlicensed assistive personnel (UAP). A client with bronchitis will need a respiratory assessment by the RN at some point, but the LPN/VN is definitely qualified to administer aerosol treatments. The third client was admitted for observation following a fall a day ago, indicating no injuries serious enough for a full admission. PNs can insert and monitor NG tubes.

A nurse is observing two unlicensed assistive personnel (UAP) changing sheets for an immobile, obese client. What unacceptable action by the UAPs would require the nurse to intervene? 1. Stands straight with feet together. 2. Asks client to lift head off the bed. 3. Pulls draw sheet with both hands. 4. Faces slightly towards head of bed.

1. Corect: When moving a client, the most important safety action for the staff doing the lifting is to spread their feet apart to shoulder width, with knees slightly bent, to prevent back injury. The feet should never be placed together. The most stable part of the body is at the hips, and moving feet apart stabilizes the lifter. The nurse would intervene in this scenario before the UAPs are injured.

Which client would be most appropriate for the emergency department charge nurse to obtain a social service consult? 1. Six year old who ingested diluted bleach. 2. Ten year old who suffered burns in a house fire. 3. Twelve year old who fractured his arm in a fight at school. 4. A 16 month old without any oral intake for the last 12 hours.

1. Correct: In most areas, laws mandate certain situations/circumstances involving children be reported to social services/child protection. Among these things are: ingestion of toxic substances, fractures, suspected neglect or abuse, burns. For older children and adults, the healthcare provider uses their judgment as to whether the situation indicates neglect or abuse by the parents or caregivers

he nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. 1.)Alert the Unit Manager. 2.)Obtain the client's vitals. 3.)Complete an incident report. 4.)Report what happened to the health care provider.

2,4,1,3 The first priority in such a situation is to check the client for any immediate problems secondary to receiving the incorrect medication and obtain a set of vitals. The client status is always your priority. Second, the nurse should notify the Health Care Provider of what happened, and implement any counter measures that may be ordered. Third, the Unit manager must be informed of this occurrence, allowing for a review of medication administration protocols and policies. This person is contacted after the client is stable. Take care of the client first. Fourth, the nurse will complete an incident report, per the facility's protocol, to assist in the identification and correction of any safety issues regarding the administration of medications.

The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which client should the nurse assess first? 1. Lumbar puncture reporting a headache. 2. Cystogram reporting burning on urination. 3. Thoracentesis reporting shortness of breath. 4. Cardiac catherization with a decreased pedal pulse below insertion site

3. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This client should report an improved respiratory, not shortness of breath. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first.

An experienced RN and LPN are working with a new nurse who has just recently passed NCLEX®. The team is assigned to care for 12 clients on the medical-surgical unit. Which factor is most important for consideration when delegating? 1. Lack of experience of the new nurse. 2. The preferences of the LPN who has experience. 3. RN's desire to avoid confrontation. 4. Assignment of equal number of clients to the RN, LPN and new nurse.

1. Correct: The lack of experience of one of the team members (the new RN) must be considered when delegating for client safety. The new nurse may not have the knowledge, assessment skills, and experience needed to care for clients who are unstable or have complex health issues.

Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Select all that apply 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Also, making a surgical bed for the client returning from surgery is a basic procedure.

A preschooler has been hospitalized for observation. The unlicensed assistive personnel (UAP) offers to sit with the child and asks the nurse to suggest an appropriate activity. The nurse knows the best activity choice for a preschool child is what? 1. Children's television show 2. Small stacking blocks 3. A checker board game 4. Children's card game

2. Correct: Preschool children, ages 3 to 5, are in the Erikson stage of "initiative versus guilt" where the learning goals involve exploration and manipulation of the environment. Motor skills are developing, and playing is used to increase self-esteem through imagination and creativity. Stacking small blocks to build structures or create creatures is definitely appropriate for this age group and can easily be done on the bedside table.

A 70 year old client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's blood pressure is 198/94 mm Hg. What would be the best action for the charge nurse to delegate at this time? 1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain.

3. Correct. Administering the client's blood pressure medicines are aimed at correcting the hypertension. The therapeutic action of furosemide is diuresis which will lower the blood pressure. Enalapril is an angiotensin converting enzyme (ACE) that treats hypertension. These medications can be administered within 30 minutes of 0900.

Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. Check the bladder for distension in the client who had a indwelling catheter removed 4 hours ago. 2. Obtain BP of client with syncope in the lying, sitting, and standing positions. 3. Prepare a sitz bath for a postpartum client. 4. Monitor for grimacing in the client who has had a stroke.

3. Correct. The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client.

The charge nurse on the postpartum unit is making assignments. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Which nurse should be assigned to care for this client? 1. The RN with 8 years' experience in the Intensive Care Unit. 2. The RN with 10 years' experience pulled from the ER. 3. The RN with 5 years' experience in the Labor and Delivery unit. 4. The RN with 2 weeks' experience on the post-partum unit.

3. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. This client needs careful monitoring and specialized care. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia

A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? 1. Administer tap water enemas until clear at 6 AM. 2. Nothing by mouth (NPO). 3. IV of D5 ½ NS at 75 mL/hour with a 20 gauge catheter. 4. Give magnesium citrate 296 mL at 3 PM today.

4. Correct: Did you notice the hint? Complete blockage of the large intestine. If you give the magnesium citrate, which is a laxative, what will happen? Nothing will get passed the complete blockage. The client would develop severe cramping. This could cause a medical emergency.

While a nurse was in shift report, four clients called the nurses' station. Which client should the nurse see first? 1. Child whose colostomy bag is leaking. 2. Three day post op client requesting pain medication. 3. Child admitted with failure to thrive, whose mother requested formula. 4. Client who needs a peak blood level drawn because the antibiotic just finished infusing.

4. Correct: The most urgent task is the peak medication level that needs to be drawn. If the level is not drawn at the appropriate time, the results may not give an accurate report of whether the medication is at the appropriate dosage or not, and if the dosage is safe

During client care rounds, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client. The primary healthcare provider writes the prescription. Which statement best describes this process? 1. Collaboration with the ancillary care providers. 2. Collaboration between the primary healthcare provider and the dietician. 3. Collaboration with the risk management team. 4. Collaboration among members of the multi-disciplinary team.

4. Correct: The nurse reporting assessment findings, the dietician suggesting a swallow evaluation, and the primary healthcare provider ordering the swallow evaluation are an example of collaboration of care among members of the multi-disciplinary team.

Which nurse would be the most appropriate for the charge nurse to assign to a 5 year old admitted in sickle cell crisis? 1. The nurse who is taking care of a 4 year old who had a routine appendectomy, a 3 year old who had bowel surgery, and a 10 year old with developmental delays. 2. The nurse who is taking care of a 6 month old with Respiratory Syncytial Virus (RSV), a 3 year old with exacerbation of asthma, and a 6 year old with a urinary tract infection for 2 weeks. 3. The nurse taking care of a 9 year old newly diagnosed with diabetes, a 6 year old with end stage renal disease, and a 2 year old with contact dermatitis. 4. The nurse taking care of a 8 year old with skeletal traction, a 5 year old with cerebral palsy, and a 12 year old with cystic fibrosis.

1. Correct: The nurse taking care of the appendectomy, bowel surgery, and developmentally delayed child has the set of clients that is less busy and has fewer client care needs. Routine appendectomy and bowel surgery will need observation and assessment but should be stable. The child with developmental delays will need assistance but no life threatening concerns with any of these clients.

The licensed practical nurse (LPN) is assisting with care for a client who has an absolute neutrophil count of 500. Which action by the LPN would warrant intervention by the RN? 1. Using an alcohol-based hand rub for hygiene before and after glove removal. 2. Advising visitor with known respiratory infection to not enter the client's room. 3. Taking fresh flowers into the client's room that were delivered by the local florist. 4. Leaving the thermometer and sphygmomanometer in the client's room.

3. Correct: First of all, did you recognize that the absolute neutrophil count (ANC) was very low? So what does this mean for this client? The neutrophils are an important component of the blood that is responsible for fighting infections. A client with a low neutrophil count is considered to be neutropenic and precautions for preventing infections are needed to protect the client. Carrying the fresh flowers into the room that were delivered by a florist may seem like a harmless gesture. But, it is not! Plants and flowers can harbor fungal spores that can be harmful to clients who are immunosuppressed. Therefore, the RN should intervene and not allow the fresh flowers to be taken into this client's room.

The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which action should the nurse interrupt the UAP from performing? 1. Draining the colostomy bag on a client with diarrhea. 2. Performing passive range of motion (ROM) on the client with right sided paralysis. 3. Placing the traction weights on the bed to transfer the client to x-ray. 4. Discarding the first urine voided by the client starting a 24 hour urine test.

3. Correct: Traction should never be relieved without a primary healthcare provider's prescription. It can result in muscle spasm and tissue damage. This client could be transferred with traction still maintained.

The nurse is explaining HIPAA regulations to a new client admitted for the first time. What statement by the nurse is most accurate regarding client's personal health information? 1. Cannot be released to other organizations without client consent. 2. May never be used for research purposes or disease tracking. 3. Permission is implied if client has family in room during exam. 4. Will not be publically released without direct client consent

3. Correct: When a client is being examined or discussing health information with the primary healthcare provider, and allows family in the room during that time, permission is then assumed. In such circumstances, under HIPAA regulations, it can be "reasonably inferred" that the client does not object to those individuals having knowledge about current healthcare information.

Which tasks can the RN delegate to an unlicensed assistive personnel (UAP) when caring for a client who has had a stroke and is being rehabilitated? Select all that apply 1. Assess a client's ability to swallow. 2. Develop a plan of care for hygiene needs. 3. Assist the client using a walker. 4. Calculating the intake and output. 5. Encourage and assist the client with the use of a hairbrush on the affected side. 6. Teach the family about the need to prevent pressure ulcers.

3., 4. & 5. Correct: It is within the role of the UAP to assist a client with a walker. The UAP can collect and calculate intake and output. When assisting the client with hygiene needs, the UAP can promote strengthening of the affected side by encouraging and assisting the client to place the hairbrush in the hand of the affected side.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 2. C-section planning discharge, post-partal infection, mastectomy. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction.

1. Correct: This group of clients is primarily med surgical.

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions of at risk clients. What steps should the QA manager include? Select all that apply 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Ask staff what fall precautions are taken for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1., 2., 4 & 5. Correct: The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the QA manager know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients to be at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply when it is time for an evaluation.

A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? Select all that apply 1. Provide "just in time" posters outlining the critical importance and steps in pain assessment. 2. Conduct brief in-services for each shift. 3. Write nurses up when pain level scale is not utilized. 4. Ensure that a complete and clear performance standard exists. 5. Assess nurses' reasons for not using pain level scale.

1., 2., 4., 5. Correct: If nurses have been provided the knowledge and performed the skill before, but the opportunity to perform is presented infrequently, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. Of course, nurses must have read the standards and understand them. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. Always assess why staff are doing or not doing what is needed for clients. There may be a lack of knowledge or there may be a sense of non-importance. Perhaps a process is not working properly. So assessment is first.

How would a case manager best describe a clinical pathway to nursing students? 1. A decision-making flowchart that uses the if/then method to address client responses to treatment. 2. A set of practice guidelines developed by a professional medical organization such as the American College of Surgeons. 3. A standardized set of preprinted primary healthcare provider prescriptions for client care, which expedite the prescription process and can be customized to individual clients. 4. A set of client care guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care.

4. Correct: A clinical pathway is a set of multi-disciplinary client care guidelines for a specific diagnosis or condition. It can be used to guide the plan of care and to identify deviations from the plan of care. These clinical pathways reduce the degree of variation in clinical practice, improves outcomes, and promote organized and effective client care based on evidenced based practice. Clinical pathways are different from algorithms, practice guidelines, and protocols because they incorporate a multidisciplinary team approach and focus on coordination and quality of care.