Leadership NCLEX questions

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first? A)A victim experiencing dyspnea B)A victim experiencing confusion C)A victim experiencing tachycardia D)A victim experiencing intense pain

A)A victim experiencing dyspnea

What is an important consideration for delegation of care by the nurse when the delegatee has limited knowledge and ability to perform the task? A)Guidance B)Expectation C)Explanation D)Responsibility

A)Guidance

A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should you delegate to a UAP? A)Reminding the patient to change positions slowly B)Assessing the patient for muscle weakness C)Teaching the patient how to collect a 24-hour urine sample D)Revising the patient's plan of care

A)Reminding the patient to change positions slowly

On your unit there are two RNs: one is a new RN while the other is an experienced RN. In addition, there are three LPNs and two nursing assistants. Which tasks delegated to one of the nursing assistants by the new RN needs to be re-evaluated? Select all that apply. A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath. B. Assist the patient with administering a Fleet Enema. C. Empty an ostomy bag. D. Collect and record patient's blood pressure, heart rate, temperature, oxygen saturation, respirations, and pain rating. E. Assist a patient with ambulation.

A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath. B. Assist the patient with administering a Fleet Enema.

The nurse calls the health care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to administered. Which action should the nurse take? A. Contact the nursing supervisor B. Administer the dose prescribed C. Hold the medication until the HCP can be contacted D. Administer the recommended dose until the HCP can be located

A. Contact the nursing supervisor

A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take? A. Immobilize the affected limb with a splint and ask him not to move. B. Make a thorough assessment of the circumstances surrounding the accident. C. Put him in semi-Fowler's position for comfort. D. Check the pedal pulse and blanching sign in both legs.

A. Immobilize the affected limb with a splint and ask him not to move.

Following a motor vehicle crash, a nurse stops and offers assistance. Which of the following actions are most appropriate? Select all that apply A. The nurse needs to know the Good Samaritan Act for the state. B. The nurse is not held liable unless there is gross negligence C. After assessing the situation, the nurse can leave to obtain help. D. The nurse can expect compensation for helping. E. The nurse offers to help but cannot insist on helping.

A. The nurse needs to know the Good Samaritan Act for the state. B. The nurse is not held liable unless there is gross negligence E. The nurse offers to help but cannot insist on helping.

A nurse is planning the client assignments for the night shift. The nursing team includes a registered nurse, a licensed practical nurse, and two unlicensed assistive personnel (UAP). Which duty (or duties) could be delegated to the UAPs? (Select all that apply.) A. Transport a client who has had a stroke to the radiology department for a computed tomography (CT) scan. B. Bathe a 25-year-old client with sickle cell disease who has multiple IV lines and a patient-controlled analgesia pump. C. Turn a 92-year-old client who has end-stage heart failure and a do-not-resuscitate (DNR) order. D. Report to the healthcare provider the fingerstick blood glucose level of 2.72 mmol/L (49 mg/dL) on a newly admitted client. E. Feed a female client who is having her first meal after she experienced a stroke.

A. Transport a client who has had a stroke to the radiology department for a computed tomography (CT) scan. B. Bathe a 25-year-old client with sickle cell disease who has multiple IV lines and a patient-controlled analgesia pump. C. Turn a 92-year-old client who has end-stage heart failure and a do-not-resuscitate (DNR) order.

There are four clients with infections in the ED and only one private room is available. Which among the clients is the most appropriate to occupy the private room? A.A client with a cough who may have tuberculosis. B.A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C). C.A client with diarrhea caused by C difficile. D.A client with a wound infected with Vancomycin-resistant enterococci (VRE).

A.A client with a cough who may have tuberculosis.

Chief nursing officers (CNOs) are accountable for establishing systems to assess, monitor, verify, and communicate ongoing competence requirements related to delegation, for both RNs and delegates. Which statements are correct? Select All That Apply. A.A key element in delegation is to assess the competency level of the staff. B.When an RN delegates a task, he or she is responsible for supervision, but is not accountable for the outcome. C.A state's nurse practice act consists of rules that govern how RNs delegate to competent staff. D.The National Council of State Boards of Nursing is opposed to delegation to unlicensed assistive personnel (UAP). E.Any traveling nurse unaware of the organizational systems in place to establish competency requirements for the unlicensed assistive persons.

A.A key element in delegation is to assess the competency level of the staff. C.A state's nurse practice act consists of rules that govern how RNs delegate to competent staff. E.Any traveling nurse unaware of the organizational systems in place to establish competency requirements for the unlicensed assistive persons.

The postpartum nurse receives report on 4 mother baby-couplets. Which tasks can be delegated to the unlicensed assistive personnel? (Select all that apply) A.Assisting the mother with morning hygiene B.Demonstrating neonate bathing technique C.Documenting intake and output on mother D.Evaluating caregiver interaction with the neonate E.Obtaining an axillary temperature of the neonate F.Swaddling the neonate after diaper changes

A.Assisting the mother with morning hygiene C.Documenting intake and output on mother E.Obtaining an axillary temperature of the neonate F.Swaddling the neonate after diaper changes

The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the licensed practical nurse (LPN)? A.Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void B.Client being discharged after DVT who needs teaching on how to self administer enoxaparin injections C.Client who has just been admitted to the telemetry unit from the emergency department with a rule-out MI D.Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg; currently is 110/62 mm Hg

A.Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void

The nurse has dealt with an emergent situation and is attempting to catch up on scheduled tasks. The nurse plans to delegate some tasks to an unlicensed assistive personnel (UAP). Which of the following tasks are within the UAP's scope of practice and appropriate for the nurse to delegate? (Select all that apply.) A.Obtain vital signs and document appropriately 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.Perform indwelling urinary catheter care and appropriately document the client's I&O. E.Perform a sterile dressing change on a CVC. F.Ensure the client takes all medication left at the bedside by the nurse.

A.Obtain vital signs and document appropriately in the client's medical record. C.Assist the client with bathing and grooming. D.Perform indwelling urinary catheter care and appropriately document the client's I&O.

A 16 year old patient with cystic fibrosis is admitted with shortness of breath and possible pneumonia. Which nursing intervention is most important to include in the patient's care? A.Perform postural drainage and chest physiotherapy q4 hours B.Allow the patient to decide whether or not they require aerosol medications C.Place the patient in a private room to prevent risk of further infection D.Plan activities to allow at least 8 hours of uninterrupted sleep

A.Perform postural drainage and chest physiotherapy q4 hours

Which description by the nurse is a correct explanation of delegation? A.The transfer of responsibility for performance of an activity B.The person's responsibility and accountability for individual actions or omissions C.The active process of directing, guiding, or influencing the outcome of an individual D.The transfer of both accountability and responsibility from one to another

A.The transfer of responsibility for performance of an activity

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? A.Vital signs B.Skin color C.Urine output D.Latest hematocrit level

A.Vital signs

Which interventions are in the scope of a licensed practical nurse (LPN)? Select all that apply. A)Client teaching B)Ambulating the client C)Interpreting lab data D)Assisting the client with bathing E)Administering intramuscular medications

B)Ambulating the client D)Assisting the client with bathing E)Administering intramuscular medications

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. A)Open doors to client rooms. B)Move beds away from windows C)Close window shades and curtains D)Place blankets over clients who are confined to bed. E)Relocate ambulatory clients from the hallways back into their rooms.

B)Move beds away from windows C)Close window shades and curtains D)Place blankets over clients who are confined to bed.

A client is found by the RN experiencing a myocardial infarction, what should the nurse administer first? A. Morphine B. Oxygen C. Sublingual Nitroglycerine D. Aspirin 81mg

B. Oxygen

The nurse received a change-of-shift report on four assigned clients. What patient should the nurse see FIRST? A. The 57-year-old client who was admitted 24 hours ago after being struck by lightning and has a serum potassium level of 5.5 mEq/L B. The 33-year-old client with a deep partial-thickness leg burn who has a temperature of 102.8F, BP 98/66 mmHg, and P 114 bpm C. The 25-year-old client admitted 1 week ago with facial and chest burns from a house fire who has been crying since recent visitors left D. The 58-year-old client who had a skin graft to a leg burn 6 hours ago and is requesting medication for pain rated at a 6 on the 0 - 10 scale.

B. The 33-year-old client with a deep partial-thickness leg burn who has a temperature of 102.8F, BP 98/66 mmHg, and P 114 bpm

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? A.A pregnant woman who exclaims, "My baby is not moving." B.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" C.A young child standing next to an adult family member who is screaming, "I want my mommy!" D.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

B.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!"

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? A.Prepare the triage rooms. B.Activate the emergency response plan. C.Obtain additional supplies from the central supply department. D.Obtain additional nursing staff to assist in treating the casualties.

B.Activate the emergency response plan.

A labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action should the nurse implement to assist in preventing a sickle cell crisis from occurring during labor? A.Continually reassure and coach the client B.Administer the prescribed oxygen throughout labor C.Maintain strict asepsis throughout the labor process D.Increase IV fluids if the client complains of feeling thirsty

B.Administer the prescribed oxygen throughout labor

The nurse receives report on the medical/surgical unit. Which client should the nurse see first? A.A client with an IV of NS at 125/hr complaining of slight swelling at the insertion site B.Client 3 days post-op total knee replacement complaining of right calf pain with movement C.Client with a respiratory rate of 24 and an O2 sat of 94% on room air D.A client 12 hours after a hysterectomy reporting nausea

B.Client 3 days post-op total knee replacement complaining of right calf pain with movement

A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? A.Repositions side to side every 2 hours B.Elevated the head of bed 60 degrees C.Auscultates the lung field every 4 hours D.Encourages deep breathing exercises every 2 hours

B.Elevated the head of bed 60 degrees

The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? A.Reassure the patient the ventilator will do the work of breathing for him. B.Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. C.Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning D.Insert an oral airway to prevent the patient from biting on the endotracheal tube

B.Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.

When caring for a victim of sexual assault, which task is most appropriate for the LPN? A.Assess for injuries B.Provide emotional support and communication C.Call for security D.Collect hair samples, swabs, and fingernail scrapings

B.Provide emotional support and communication

Which client should the postpartum nurse assess first after receiving the a.m. shift report? A.The client who is complaining of perineal pain when urinating. B.The client who saturated multiple peri-pads during the night. C.The client who is refusing to have the newborn in the room. D.The client who is crying because the baby will not nurse.

B.The client who saturated multiple peri-pads during the night.

The graduate nurse is interviewed by the manager of a unit and is told that the manager's leadership style is laissez-faire or one of letting the staff nurses make the decisions about the unit's operations. Which question by the graduate nurse indicates the best understanding of the laissez-faire leadership style? A: "As the manager, do you maintain control and make all decisions?" B: "As the manager, do you assume a passive, nondirective approach?" C: "As the manager, do you facilitate decision making within the group?" D: "As the manager, do you change style according to the needs of the group?"

B: "As the manager, do you assume a passive, nondirective approach?"

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? A)A middle-aged man with 1 foot trapped under the wreckage B)A crying teenager who is holding pressure on an arm laceration C)A young woman who appears dazed and confused and is shivering D)A screaming middle-aged woman looking frantically for her husband

C)A young woman who appears dazed and confused and is shivering

What factors are most important for the nurse to consider when delegating responsibilities? A)Preferences of the clients and staff B)Physical Layout of the unit and client rooms C)Staff member's level of education and expertise D)Client's diagnosis and length of time in the hospital

C)Staff member's level of education and expertise

A client with asthma and depression is admitted to the hospital. Which tasks delegated by the delegator would indicate the task is applicable for the registered nurse? A)Administer oral antidepressants B)Administer a pain killer IM C)Teach the client how to use the meter dose inhaler D)Reinforce tips for stress management with the client

C)Teach the client how to use the meter dose inhaler

The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant? A. Assist with the intubation B. Placing the defibrillator pads C. Doing chest compressions D. initiating bag valve mask ventilation

C. Doing chest compressions

Which task is appropriate for the registered nurse to delegate to the UAP? A.Assist a patient who is postoperative hip replacement to ambulate with their walker for the first time B.Change the disposable tracheostomy cannula for a new postoperative tracheostomy patient if secretions are thick and tenacious C.Obtain a sterile urine sample from a patient with a foley catheter that is connected to a closed drainage system D.Evaluate a patient's ability to swallow ice after a gastroscopy

C. Obtain a sterile urine sample from a patient with a foley catheter that is connected to a closed drainage system.

A patient is admitted to a Cardiac Stepdown Unit with a diagnosis of Hypokalemia. What intervention should the nurse complete first? A.Administer the clients scheduled dose of Lasix B.Obtain a 12 Lead EKG C. Place the client on a Cardiac Monitor D. Obtain an order for the patient to have a new serum potassium level drawn

C. Place the client on a Cardiac Monitor

A medical surgical staff nurse is floated to the telemetry unit to help with client care. From the list of clients, who would be most appropriate to assign to the nurse? Select all that apply. A. the client admitted with new onset a-fib B. client admitted 1 day ago with a repair of a carotid endarterectomy (CEA) C. Client admitted yesterday with a stable, third-degree heart block awaiting a pacemaker evaluation D. client admitted during night with normal sinus rhythm and has a repair of a small bowel obstruction E. client admitted 2 days ago who received tissue plasminogen activator (tPA) for an ischemic stroke and had lab studies and x-rays done

C. client admitted yesterday with a stable, third-degree heart block awaiting pacemaker evaluation D. the client admitted with normal sinus rhythm and has a repair of small bowel obstruction

A nurse on a medical surgical unit has received the shift change report from the previous night and will care for four clients. Which of the following clients needs should the nurse assign to a UAP? A. feeding a client who was admitted 24 hours ago with aspiration B. reinforcing teaching with a client who is learning to walk using a cane C. reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer

C. reapplying a condom cath

The nurse from the psychiatric unit is reassigned to the pediatric unit. Which client assignment is the 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.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.

A nurse's spouse is scheduled for exploratory surgery at the hospital where the nurse is employed. Which practice is most appropriate regarding the spouse's medical record and treatment? A.Because the nurse is an employee, she is allowed to access his chart B.The nurse is allowed to access the chart based on their relationship C.Access to the chart requires a signed release form D.The nurse can ask the surgeon to discuss the outcome

C.Access to the chart requires a signed release form

A nurse notices that the physician has prescribed an unusually large dose of a medication. What is the appropriate nursing action? A.Refuse to administer the medication B.Call the Pharmacist C.Notify the Prescribing Physician D.Administer the Medication

C.Notify the Prescribing Physician

Criteria can be used to assess co-workers competency for delegation. Which of the following methods can be used to assess competency of nursing assistive personnel? Select all that apply. A. Micro-managing and being able to step in and take over tasks B.Educating and training for the required role function C.Supervising with periodic review and performance feedback D.Orienting to the job description and evaluating tasks within a designated time frame E.Checking with unlicensed assistant when completing the task to obtain feedback about the patient

C.Supervising with periodic review and performance feedback D.Orienting to the job description and evaluating tasks within a designated time frame E.Checking with unlicensed assistant when completing the task to obtain feedback about the patient

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? A.Obtain a court order for the surgical procedure B.Ask the EMS team to sign the informed consent C.Transport the victim to the operating room for surgery D.Call the police to identify the client and locate the family

C.Transport the victim to the operating room for surgery

Place the following clients in the order that the nurse should see them: a.) A client admitted for an acute asthma attack with respirations of 24 and a pulse ox reading of 91% b.) A patient who broke their radius in a motor vehicle accident complaining of 7/10 pain. c.) A Patient with a GI bleed that was on the call bell asking why they are not allowed to have cherry jell-o with their dinner d.) A client admitted for pneumonia who during shift report is now experiencing newly onset stridor

D then A then B then C

After successful treatment of clients involved in a mass casualty incident, the incident commander deactivates the emergency response plan. Which activity is most important for the emergency department (ED) charge nurse to initiate at this time? A)Analyze the ED response to the mass casualty incident. B)Follow up with survivors to determine the need for additional referrals. C)Initiate critical incident stress debriefing (CISD) for staff members. D)Take inventory and restock the ED with supplies and equipment

D)Take inventory and restock the ED with supplies and equipment

Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? A. An unintentional tort B. Assault C.Invasion of Privacy D. Battery

D. Battery

when creating an assignment for a team consisting of a registered nurse, 1 LPN, 2 UAPs, which is best client for the LPN? A. a client requiring frequent temperature checks B. client requiring assistance with ambulation q4 hours C. client on a mechanical vent requiring frequent assessment and suction D. client with a spinal cord injury requiring urinary catheterization q6 hours

D. Client with SCI requiring catheterization

You have just received nursing report from the previous shift and you are performing your morning patient assessments. You have a total of 4 patients that are either post-op or pre-op for surgery. Which patient should the nurse see first? A. Orange-colored urine in a patient who is taking Pyridium and is post-op day 3 from a TURP. B. No stool excretion in a patient who is post-op day 2 from a colostomy. C. Shoulder pain in a patient who is post-op day 1 from a laparoscopic cholecystectomy. D. Pain rating that has decreased from a 10 to 0 in a patient who is awaiting an appendectomy.

D. Pain rating that has decreased from a 10 to 0 in a patient who is awaiting an appendectomy.

A student attending University was found unconscious in his dorm room after ingesting a poisonous substance, what is the priority intervention the roommate should take? A. Turn him and try to make him vomit B. Call poison control C. Start CPR D. Remove any foreign material from the mouth

D. Remove any foreign material from the mouth

What legal complications might a nurse face for using restraint without legal warrant on a client? A. The nurse may be charged with libel. B. The nurse may be charged with negligence. C. The nurse may be charged with malpractice. D. The nurse may be charged with false imprisonment

D. The nurse may be charged with false imprisonment

After a shift change, you are assigned to care for the following patients. Which patient do you assess first? A.A 60 year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab B.A 55 year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation C.A 70 year old with pneumonia who needs to be started on intravenous antibiotics D.A 50 year old with asthma who complains of shortness of breath after using a bronchodilator

D.A 50 year old with asthma who complains of shortness of breath after using a bronchodilator

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? A.A client who requires a bed bath B.An older client requiring frequent ambulation C.A client who requires hourly vital sign measurements D.A client requiring abdominal wound irrigations and dressing changes every 3 hours

D.A client requiring abdominal wound irrigations and dressing changes every 3 hours

3). The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A.A postoperative client preparing for discharge with a new medication B.A client requiring daily dressing changes of a recent surgical incision C.A client scheduled for a chest x-ray after insertion of a nasogastric tube D.A client with asthma who requested breathing treatment during the previous shift

D.A client with asthma who requested breathing treatment during the previous shift

A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on: A.Comfort level B.Activity tolerance C.Level of consciousness D.Hydration and nutrition status

D.Hydration and nutrition status

The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client? A.Obtain informed consent from the client for the diagnostic procedure. B.Discuss the need to increase oral fluid intake after the procedure. C.Explain to the client that he or she will have to drink a white, chalky substance. D.Tell the client not to eat or drink anything prior to the procedure.

D.Tell the client not to eat or drink anything prior to the procedure.

A 25 year old client comes to the ED with a laceration to the head. The patient is complaining that he has no feeling in his legs. When assessing the patient he has a respiratory rate of 18, palpable pulses, and a cap refill of 2 seconds. Which category would be assigned to this patient? A.Green B.Red C.Black D.Yellow

D.Yellow

A nurse is scheduling a client for diagnostic studies of the gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last? a) ultrasound b) colonoscopy c) barium enema d) computed tomography

c) barium enema

A primary care provider's orders indicated that a surgical consent form needs to be signed. Since the nurse was not present when the primary care provider discussed the surgical procedure, which statement "best" illustrates the nurse fulfilling the client advocate role? a. "The doctor has asked that you sign the consent form." b. "Do you have any questions about the procedure?" c. "What were you told about the procedure you are going to have?" d. "Remember that you can change your mind and cancel the procedure."

c. "What were you told about the procedure you are going to have?"