NCLEX
A client comes to the clinic for a diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle? 1. Intradermal all injection is less painful. 2. Intruder all drugs are easier to administer. 3. Intruder all drugs diffuse more rapidly. 4. Intruder all drugs diffuse more slowly.
RATIONALE: Drugs administered intradermally (injected between the skin layers just below the surface stratum corneum) diffuse slowly into the local micro capillary system. Slow diffusion is necessary during diagnostic allergy testing because rapidly introducing an allergen could cause a life-threatening allergic reaction in a sensitive client. The ease of administration and client comfort aren't principles taken into account when using intradermally injections for allergy testing.
A nurse correctly identifies which items as belonging to the dorsal cavity? 1. Mediastinum 2. Mouth 3. Vertebral canal 4. Reproductive organs
RATIONALE: The dorsal cavity consists of the cranial (skull) and vertebral canal (spinal cavity). The mediastinum and reproductive organs are located in the ventral cavity. The mouth is located in the oral cavity.
Which guidelines define and regulate what the nurse May and may not do as a professional? 1. State legislature 2. Facility policies and procedures 3. Standards of care 4. Nurse practice act
RATIONALE: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.
Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. 1. Assessing a client's pain 2. Taking a client's vital signs 3. Documenting a client's oral intake 4. Performing a blood glucose check 5. Evaluating a client's response to a blood pressure medication
RATIONALE: Registered nurses are responsible for all phases of the nursing process. These responsibilities include assessing a client's pain and evaluating a client's response to treatment. A nurse may delegate tasks such as taking vital signs, documenting intake and output, and performing blood glucose checks if she follows the five rights of delegation. The five rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person s competent to perform the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows-up on the task after it has been completed.
A nurse-manager appropriately behaves as an autocrat in which situation? 1. Planning vacation time for staff 2. Directing staff activities if a client experiences a cardiac arrest 3. Evaluating a new medication-administration process 4. Identifying the strengths and weaknesses of a client-education video
RATIONALE: in a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.
