NCLEX Prep Questions

The nurse is working with an experienced unlicensed assistive personnel (UAP) and an LPN/LVN on the telemetry unit. A client who had an acute myocardial infarction 3 days ago has been reporting fatigue and chest discomfort when ambulating. Which nursing activity included in the care plan is best assigned to the LPN/LVN? 1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities 2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation 3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand. 4. Explaining the rationale for alternating rest periods with exercise to the client and family

1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities Rationale: Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice.

Which tasks are appropriate to assign to an LPN/LVN who is functioning under the supervision of an RN? Select all that apply. 1. Administering sulfacetamide sodium 10% to a child with conjunctivitis 2. Reviewing hand-washing and hygiene practices with clients who have eye infections 3. Showing clients how to gently cleanse eyelid margins to remove crusting 4. Assessing nutritional factors for a client with age-related macular degeneration 5. Reviewing the health history of a client to identify risk for ocular manifestations 6. Performing a routine check of a client's visual acuity using the Snellen eye chart

1. Administering sulfacetamide sodium 10% to a child with conjunctivitis 2. Reviewing hand-washing and hygiene practices with clients who have eye infections 3. Showing clients how to gently cleanse eyelid margins to remove crusting 6. Performing a routine check of a client's visual acuity using the Snellen eye chart Rationale: Administering medications, reviewing and demonstrating standard procedures, and performing standardized assessments with predictable outcomes in noncomplex cases are within the scope of the LPN/LVN. Assessing for systemic manifestations and behaviors, risk factors, and nutritional factors is the responsibility of the RN.

The charge nurse assigns the nursing care of a patient who has just returned from open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which instructions would the RN provide for the LPN/LVN? Select all that apply. 1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 4. The patient will no longer need pain medication. 5. Check the neurovascular status of the fingers every hour. 6. Instruct the patient to perform range of motion on the affected wrist.

1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 5. Check the neurovascular status of the fingers every hour. Rationale: Postop, patients undergoing open carpal tunnel release surgery experience pain and numbness, and their discomfort may last for weeks to months. Hand movements may be restricted for 4 - 6 weeks after surgery. All of the other directions are appropriate for the post-op care of this patient. It is important to monitor for drainage, tightness, and neurovascular changes. Raising the hand and wrist above the heart reduces the swelling from surgery, and this is often done for several days.

The nurse is working with unlicensed assistive personnel (UAP) to provide care for six patients. At the beginning of the shift, the nurse carefully tells the UAP what patient interventions and tasks he or she is expected to perform. Which "Four Cs" guide the nurse's communication with the UAP? Select all that apply. 1. Clear 2. Comprehensive 3. Concise 4. Credible 5. Correct 6. Complete

1. Clear 3. Concise 5. Correct 6. Complete Rationale: Clear, concise, correct, complete are the "Four Cs" of communication. Implementing the four Cs of communication helps the nurse ensure that the UAP understands what is being said; that the UAP does not confuse the nurse's directions; that the directions comply with policies, procedures, job descriptions, and the law; and that the UAP has all the information necessary to complete the tasks assigned.

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem? 1. Humidify the patient's oxygen. 2. Use a simple face mask instead of a nasal cannula. 3. Provide the patient with an extra pillow. 4. Have the patient sit up in a chair at the bedside.

1. Humidify the patient's oxygen. Rationale: When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply. 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Assess skin turgor by pinching the skin over the back of the hand 4. Observing the lips, tongue, and mucous membranes 5. Providing mouth care every 2 hours while the client is awake 6. Seeking a dietary consult to increase fluids on meal trays

1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 4. Observing the lips, tongue, and mucous membranes 5. Providing mouth care every 2 hours while the client is awake Rationale: The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain agents such as alcohol. To assess skin turgor in an older adult, skin tenting is best checked by pinching the skin over the sternum or on the forehead rather than the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary consult is within the purview of the RN or health care provider.

When administering a blood transfusion to a patient, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Take the patient's vital signs before the transfusion is started. 2. Assure that the blood is infused within no more than 4 hours. 3. Ask the patient at frequent intervals about presence of chills or dyspnea. 4. Assist with double-checking the patient's identification and blood bag number.

1. Take the patient's vital signs before the transfusion is started. Rationale: UAP education and role includes obtaining vital signs, which will be reported to the RN prior to the initiation of the transfusion. Monitoring for transfusion reactions, adjusting transfusion rate, and assuring that the blood type and number are correct require critical thinking and should be done by the RN.

In the care of a patient with neutropenia, what tasks should the nurse instruct unlicensed assistive personnel (UAP) to perform? Select all that apply. 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique

1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 4. Gathering the supplies to prepare the room for protective isolation 6. Practicing good hand-washing technique Rationale: Measuring vital signs and reporting on specific parameters, practicing good hand washing, and gathering equipment are within the scope of duties for a UAP. Assessing for symptoms of infections and superinfections is the responsibility of the RN.

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assess puncture site and dressing for leakage 2. Check vital signs every 15 minutes for 1 hour 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths 5. Take the specimens to the lab 6. Teach the patient symptoms of pneumothorax

2. Check vital signs every 15 minutes for 1 hour 4. Remind the patient to take deep breaths 5. Take the specimens to the lab Rationale: Checking vital signs, carrying specimens to the lab, and reminding patients about what has already been taught are actions that are within the scope of practice for UAP. Assessing and teaching patients requires additional knowledge and training that is within the scope of practice for professional nurses.

The nurse is working in a hospice facility for patients with acquired immunodeficiency syndrome (AIDS). The facility is staffed with LPNs/LVNs and unlicensed assistive personnel (UAP). Which action will the nurse assign to the LPN/LVN? 1. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition 2. Collecting data about the patients' responses to medications used for pain and anorexia 3. Developing UAP training programs about how to lower the risk for spreading infections 4. Assisting patients with personal hygiene and other activities of daily living as needed

2. Collecting data about the patients' responses to medications used for pain and anorexia Rationale: The collection of data used to evaluate the therapeutic and adverse effects of medications is included in LPN/LVN education and scope of practice. Assessment, planning, and developing teaching programs are more complex skills that require RN education. Assistance with hygiene and activities of daily living should be delegated to the UAP.

The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake

2. Providing straws and offering fluids between meals Rationale: UAPs can reinforce additional fluid intake when it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN. Test Taking Tip: The nurse must be familiar with the scope of practice for UAPs before delegating client care tasks. UAP scope of practice includes checking vital signs, tasks associated with activities of daily living such as bathing and oral care, feeding, and recording intake and output. UAPs can provide items such as drinking straws and can encourage and remind clients about instructions from the nurse such as increasing fluid intake.

The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives

2. Setting up oxygen and suction equipment Rationale: The LPN/LVN scope of practice includes setting up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins.

The charge nurse observes an LPN/LVN assigned to provide all of these interventions for a patient with Paget disease. Which action requires that the charge nurse intervene? 1. Administering 600 mg of ibuprofen to the patient 2. Encouraging the patient to perform exercises recommended by a physical therapist 3. Applying ice and gentle massage to the patient's lower extremities 4. Reminding the patient to drink milk and eat cottage cheese

3. Applying ice and gentle massage to the patient's lower extremities Rationale: Applying heat, not ice, is the appropriate measure to help reduce the patient's pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by a physical therapist would be nonimpact in nature and provide strengthening for the patient. A diet rich in calcium promotes bone health. Test Taking Tip: The charge nurse would be familiar with the usual care of a patient with Paget disease. Supervise the LPN/ LVN so that he or she would stop the ice treatment and explain to the LPN/LVN that the use of heat is preferable to reduce the patient's pain.

The postoperative care of a morbidly obese client is being planned. Which task best uses the expertise of the LPN/LVN, under the supervision of the RN team leader? 1. Obtaining an oversized blood pressure cuff and a large-size bed 2. Setting up a reinforced trapeze bar 3. Assisting in the planning of toileting, turning, and ambulation 4. Assigning tasks to unlicensed assistive personnel (UAP) and other ancillary staff

3. Assisting in the planning of toileting, turning, and ambulation Rationale: The LPN/LVN can offer valuable assistance in planning the interventions, but the RN has ultimate responsibility for the care plan. The LPN/LVN can delegate and assign tasks to UAPs; however, if the RN is the team leader, it is better if UAPs are not receiving instructions from multiple people. Obtaining equipment should be delegated to a UAP. A physical therapist should be contacted to set up specialized equipment.

After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Documenting the seizure 2. Performing neurologic checks 3. Checking the client's vital signs 4. Restraining the client for protection

3. Checking the client's vital signs Rationale: Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements, if necessary, to prevent injury.

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the unlicensed assistive personnel (UAP) who is assisting with the client's care? 1. Teaching the client and family members about means to prevent transmission of VRE 2. Communicating with other departments when the client is transported for ordered tests 3. Implementing contact precautions when providing care for the client 4. Monitoring the results of ordered laboratory culture and sensitivity tests

3. Implementing contact precautions when providing care for the client Rationale: All hospital personnel who care for the client are responsible for correct implementation of contact precautions. The other actions should be carried out by licensed nurses, whose education covers monitoring of laboratory results, client teaching, and communication with other departments about essential client data.

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant Staphylococcus aureus (VRSA). Which nursing action can be assigned to an LPN/LVN? 1. Planning ways to improve the client's oral protein 2. Teaching the client about home care of the leg ulcer 3. Obtaining wound cultures during dressing changes 4. Assessing the risk for further skin breakdown

3. Obtaining wound cultures during dressing changes Rationale: LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. Teaching, assessment, and planning of care are complex actions that should be carried out by the RN.

In the care of a client with gastroesophageal reflux disease, which task would be appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Sharing successful strategies for weight reduction 2. Encouraging the client to express concerns about lifestyle modification 3. Reminding the client not to lie down for 2 to 3 hours after eating 4. Explaining the rationale for eating small frequent meals

3. Reminding the client not to lie down for 2 to 3 hours after eating Rationale: Reminding the client to follow through on advice given by the nurse is an appropriate task for the UAP. The RN should take responsibility for teaching rationale, discussion strategies of the treatment plan, and assessing client concerns.

The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered

4. Applying oxygen per nasal cannula as ordered Rationale: The LPN/LVN is well trained to administer 02 via nasal cannula. This client is considered unstable; therefore, the RN should take responsibility for administering drugs and monitoring responses to therapy, which include the effects on the respiratory system. The RN should also take responsibility to communicate with the HCP for ongoing treatment and therapy.

Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged

4. Disinfecting blood pressure cuffs after clients are discharged Rationale: The UAP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and those tasks should be performed by licensed nurses.

A nurse manager is planning daily work and activities for the unit. Which of the following actions is the nurse manager's priority? a. Assign client care to staff b. Coordinate staff breaks c. Organize daily meetings using an appointment book d. Review long-terms goals of the unit

a?

a nurse overhears two staff members in the facility elevator discussing a client's care. Which of the following actions should the nurse take? a. Clarify the client information the staff members are discussing b. Send the staff members home for the day c. Report the incident to the nurse manager d. Inform the client about the breach of confidentiality

c?