NCLEX Unit 2 Questions

A client experiences cardiac arrest. The nurse leader quickly response to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? A. Autocratic B. Situational C. Democratic D. Laissez-faire

A

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first? A. A client scheduled for a chest x-ray B. A client requiring daily dressing changes C. A postoperative client preparing for discharge D. A client receiving oxygen who is having difficulty breathing

D

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice? A. A task approach method is used to provide care to clients. B. Managed care concepts and tools are used when providing client care. C. Nursing staff are led by the nurse when providing care to a group of clients. D. A single registered nurse is responsible for providing nursing care to a group of clients.

C

The nurse is caring for a group of clients who were taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications? A. A 60-year-old male client with rhinitis B. A 24-year-old male client with a lower back injury C. A 10-year-old female client with a urinary tract infection D. A 45-year-old female client with a history of migraine headaches

C

The nurse is planning to reinforce nutrition instructions to an African-American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African-American heritage? A. Raw fish B. Red meat C. Fried foods D. Rice as the basis for all meals

C

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? A. Unwrapping the eating utensils for the client B. Replacing the plastic utensils with metal utensils C. Carefully transferring the food from paper plates to glass plates D. Allowing the client to unwrap the utensils and prepare his own meal for eating

D

The nurse observes that a client received pain medication one hour ago from another nurse, but the client still has severe pain. The nurse has previously observed the same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action? A. Report the information to the police. B. Call the impaired nurse organization. C. Talk with the nurse who gave the medication. D. Report information to a nursing supervisor.

D

The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the clients being cared for on the nursing unit. How should the nurse proceed to implement a quality improvement program?

The nurse should collaborate with the RN and assist to collect data about the problem. This data should include information such as the primary and secondary diagnoses of clients developing infection, the type of IV catheters being used, the site of the catheter, IV site dressings being used, frequency of assessment and methods of care for the IV site, and the length of time that the IV catheter has been inserted.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? A. Call the hospital lawyer. B. Call the nursing supervisor. C. Refuse to float to the pediatric unit. D. Report to the pediatric unit and identify tasks that can be safely performed.

D

The nurse consults with the dietitian regarding the dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan? A. Rice B. Fruits C. Red meat D. Fried foods

A

The nurse is preparing a client for an echocardiogram and notes that the client is wearing a religious medal on a chain around the neck. What should the nurse do with regard to removing this personal item from the client?

The nurse should ask the client about the significance of such an item and it's removal because it may have cultural or spiritual significance. The nurse should also determine whether the item will compromise client safety or test results. If so, then the nurse should ask the client if the item can either be removed temporarily or placed on another part of the body during the procedure.

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? A. A client who wears wound irrigation B. A client who requires frequent ambulation C. A client who is receiving continuous tube feedings D. A client who requires frequent vital signs after a cardiac catheterization

B

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asked the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response? A. "I have a legal obligation to report this type of abuse." B. "I promise I won't tell anyone, but let's see what we can do about this." C. "Let's talk about ways that will prevent your daughter from hitting you." D. " this should not be happening. If it happens again, you must call the emergency department."

A

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assigned to the unlicensed assistive personnel (UAP)? A. A client who requires a 24 hour urine collection B. A client who requires twice daily dressing changes C. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures D. A client who has been placed on a bowel management program and requires rectal suppositories and a daily enema

A

The client asked the nurse about various herbal therapies available for treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary healthcare provider? A. Garlic B. Valerian C. Lavender D. Glucosamine

B

The nurse finds the client lying on the floor. The nurse calls the register nurse, who checks the client and then calls the nursing supervisor and the primary healthcare provider to inform them of the occurrence. The nurse completes the incident report for which purpose? A. Providing clients was necessary stabilizing treatments B. A method of promoting quality care and risk management C. Determining the effectiveness of interventions in relation to outcomes D. The appropriate method of reporting to local, state, and federal agencies

B

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? (select all that apply) A. "An event is termed a mass casualty when it overwhelms local medical capabilities." B. "Mass casualty events do not require an increase in the number of staff that are needed." C. "A mass casualty event occurs only within the healthcare facility and can endanger staff." D. "Mass casualty events may require the collaboration of many local agencies to handle the situation." E. " A mass casualty event occurs if a fight between visitors occurs in the emergency department."

B C E

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? A. Call the nursing supervisor to initiate a court order for the surgical procedure. B. Try calling the client's spouse to obtain telephone consent before the surgical procedure. C. Ask the friend who accompanied the client to the emergency department to sign the consent form. D. Transport the client to the operating department immediately without obtaining an informed consent.

D

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? A. A client complaining of muscle ache, headache, and malaise B. A client who twisted their ankle when they fell in line skating C. A client with a minor laceration on the index finger sustained while cutting an egg plant D. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

D

Which identifies accurate nursing documentation notations? (Select all that apply) A. The client slept to the night. B. Abdominal wound dressing is dry and intact without drainage. C. The client seemed angry when a weekend for vital sign measurement. D. The client appears to be anxious when it is time for respiratory treatments. E. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

A B E

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks? A. Document of the task was completed. B. Assigned the task that were not completed to the next nursing shift. C. Allow each staff member to make judgments when performing the task. D. Perform follow up with each staff member regarding the performance and outcome of the task.

D

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, " I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement? A. "I would try anything that I could if I had cancer." B. "No, because it will interact with the chemotherapy." C. "Tell me what you know about complementary therapies." D. "You need to ask your primary healthcare provider about it."

C

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asked a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? A. Threatening to place a client in restraints B. Performing a surgical procedure without consent C. Taking photographs of the client without consent D. Telling the client that he or she cannot leave the hospital

C

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client? A. "Herbal substances are not safe and should never be used." B. "I will teach you how to take your blood pressure so that it can be monitored closely." C. "You will need to talk to your primary healthcare provider before using an herbal substance." D. "If you take an herbal substance, you will need to have your blood pressure checked frequently."

C

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary healthcare provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident? A. Place the incident report in the client's chart. B. Make a copy of the incident report for the PHCP. C. Document a complete entry and the client's record concerning the incident. D. Document in the client's record that an incident report has been completed.

C

A Hispanic American mother brings her child to the clinic for examination. Which is the most important when gathering data about the child? A. Avoiding eye contact B. Using body language only C. Avoiding speaking to the child D. Touching the child during the examination

D

A client has died, and the nurse asked a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? A. Show acceptance of feelings. B. Provide information needed for decision-making. C. Suggest a referral to a mental health professional. D. Remain with a family member without discussing funeral arrangements.

D

The nurse is assigned to care for for clients. When planning client rounds, which client should the nurse check first? A. A client in skeletal traction B. A client who is dependent on a ventilator C. A post operative client preparing for discharge D. A client admitted during the previous shift with a diagnosis of gastroenteritis

B

The nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is the lowest priority during the data collection? A. Respiratory B. Psychosocial C. Neurological D. Cardiovascular

B

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

A

The nurse is recording a nursing hands-off (end- of- shift) report for a client. Which information needs to be included? A. As needed medications given that shift B. Normal vital signs that have been normal since admission C. All of the tests and treatments the client has had since admission D. Total number of scheduled medications that the client received on that shift

A

A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? (select all that apply) A. Many choose not to have health insurance. B. They believe that health is a gift from God. C. The authority of women is equal to that of men. D. They remain secluded and avoid helping others. E. They use both traditional and alternative healthcare, such as healers, herbs, and massage. F. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment.

A B E F

While preparing a client for surgery scheduled in one hour, the client states to the nurse, "I have change my mind. I don't want this surgery." What should the nurse do?

The nurse should further investigate the clients request and assess his or her concerns about not wanting the surgery. The surgeon should then be contacted so that they can discuss the consequences of not having the surgery with the client. The nurse should document the clients request and notification of PHCP to demonstrate complete critical thinking about the scenario. It is the client's right to refuse treatment.