Leadership: NCLEX Questions
An RN is caring for an 80-year-old male patient who has been admitted to the hospital. The RN delegates several tasks to the UAP. In order to evaluate the understanding of the UNP, the RN asks the UAP to describe which tasks have been delegated. Which responses given by the UNP indicate effective understanding of the tasks? Select all that apply. ' a. "I must assist the patient with oral care." b. "I must assess the patient's health status." c. "I must administer intravenous drug pain medication." d. "I must record the blood pressure of the patient at regular intervals."
Answer A and D. Rationale: The registered nurse delegates the tasks to the UAP based on capabilities and skills of the UNP. The UAP can perform tasks that involve basic hygiene. The UAP can also perform tasks to record vital signs. Assessment of the patient's health status and intravenous drug medication administration are within the scope of practice of the RN.
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
Answer A, B, E. Rationale: The nurse is subject to the limitations of state law and should be familiar with the Good Samaritan laws in the specific state. Gross negligence (conscious/voluntary recklessness) would be described by the individual state law. Unless there is another equally or more qualified person present, the nurse needs to stay until the injured person leaves. The nurse should ask someone else to call or go for additional help. The same client rights apply at the scene of an accident as well as those in the workplace, so they cannot insist on helping or expect compensation.
Which are examples of internal disasters that must be accounted for when formulating a disaster response plan? Select all the apply. a. Fire b. Hurricane c. Earthquake d. Power Outage e. Act of Terrorism
Answer A, D. Rationale: Fire and Power Outage are considered internal disasters because they can happen within the hospital. All the other responses are examples of external disasters. They happen outside the hospital and often bring people in who need care.
A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag
Answer A, D. Rationale: Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag
The nurse is making telemetry unit assignments. Which patient assignment should be given to the licensed practical nurse? a. Client 2 days after having aortic valve surgery who needs a urinary catheter inserted due to inability to void. b. Client discharged after DVT who needs teaching on Lovenox administration. c. Client recently admitted to unit with suspected myocardial infarction. d. Client on a nitroglycerin infusion drip with titration prescription from MD.
Answer A. Rationale A: Inserting a urinary catheter is within the scope of practice for the LPN. This patient is predictable and stable. B: The RN is responsible for initial teaching. The LPN is able to reinforce previous teaching. C: This patient requires frequent clinical assessment and judgment due to the potential MI. D: Nitroglycerin drips/titrations are complex and would be best suited for an RN
Which statement represents a situation is which delegation is ineffective or inappropriate? a. The RN asks the LPN to assist with admissions by assessing the clients as they get to their rooms. b. The RN delegates administration of oral medications for a group of clients to the LPN. c. The LPN directs the unlicensed assistant to report vital sign changes on a postoperative client to the RN. d. The nurse manager asks the RN to act as chairperson for today's unit council meeting since the charge nurse went home sick.
Answer A. Rationale A: The RN is the only caregiver legally responsible for assessing clients. Thus, the RN cannot delegate this to the LPN, and this is an example of over delegation. B: It is within the LPNs scope of practice to administer oral medications. C: The LPN can delegate tasks to the unlicensed assistant. Reporting vital sign changes to the RN is within the scope of an unlicensed assistant. D: The nurse manager can delegate to the RN. An RN is a logical substitute for the charge nurse in this situation.
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action net? a. Reassess the client b. Conduct a staff meeting to describe the fall c. Document in the nurse's notes that an incident report was completed. d. Contact the nursing supervisor to update information regarding the fall
Answer A. Rationale: Reassess the patient. Rationale ~ After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary
A nurse is assigned to provide care to a client in labor and will care for the client throughout labor and into the postpartum period. The nurse assists in developing a plan of care and determines that the priority assessment in the fourth stage of labor is which of the following? a. Assessing the uterine fundus and lochia b. Checking the mother's temperature c. Encouraging food and fluid intake d. Providing privacy for the parents and their newborn infant
Answer A. Rationale: The fourth stage of labor is the stage of physical recovery for the mother and newborn infant. It lasts from the delivery of the placenta through the first 1 to 4 hours after birth. A potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted and that vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours. Although options B, C, and D are also interventions during this stage, they are not the priority.
A triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority? a. Administer oxygen therapy via nasal cannula b. Notify the physician c. Complete history taking d. Put the client on ECG monitoring
Answer A. Rationale: The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed after oxygen therapy is started.
The nurse is assigned to telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform? A. Removing the stinger by scraping it B. Applying a cold compress C. Taking an oral antihistamine D. Calling 911
Answer A: Rationale: the stinger will continue to release venom into the skin, and so removing the stinger should be the first action that the nurse should direct to the client. Options B (cold compress) and option C (antihistamine) would be steps to take following the removal of the stinger. Option D (call 911) would be chosen if the patient was experiencing more severe symptoms.
Which of the following tasks is appropriate for the nurse to delegate to an experienced UAP? a. Obtain a 24-hour diet recall from a client recently admitted with anorexia nervosa. b. Obtain a clean-catch urine specimen from a client suspected of having a urinary tract infection. c. Observe the amount and characteristics of the returns from a continuous bladder irrigation for a client after a transurethral resection. d. Observe a client newly diagnosed with diabetes mellitus practice injection techniques using an orange.
Answer B Rationale: A nurse is able to delegate activities which involve standard, unchanging procedures. There is no indication that the client has a catheter, so this is seen as a routine procedure. Option A and C both involve an assessment, while option D requires the evaluation of client teaching.
When assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN under the supervision of the RN? a. A patient with severe anemia secondary to GI bleeding b. A patient who needs enemas and antibiotics to control GI bacteria c. A patient who needs preoperative teaching for bowel resection surgery d. A patient who needs central line insertion for chemotherapy
Answer B Rationale: Administering enemas and antibiotics are within the scope of practice of LPNs. Although some states and facilities may allow the LPN to administer blood, in general, administering blood, providing preoperative teaching, and assisting with central line insertion are the responsibilities of the RN.
A hospitalized client with type 1 diabetes mellitus tells the nurse that they feel like they are having a hypoglycemic reaction. The nurse should complete which action first? A. Prepare to administer 50% dextrose intravenously. B. Obtain a blood glucose reading. C. Give the client 4 oz (120 mL) of orange juice. D. Prepare to administer subcutaneous glucagon hydrochloride
Answer B Rationale: Management of hypoglycemia depends on the severity of the reaction.
A nurse who works the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid. Which is the most appropriate action by the nurse? A. Call the police B. Call the nursing supervisor C. Call security D. Lock the coworker in the medication room until help is obtained
Answer B Rationale: Nurse practice acts require reporting impaired nurses. This occurrence needs to be reported to the nurse supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs.
You are the supervising nurse in an Emergency Department (ED) following a mass casualty. Which of the following patients is improperly tagged by your staff? a. Black: A 32 y/o female patient with extensive head injuries, a thready pulse and agonal breathing. b. Yellow: A 57 y/o male patient limping with several minor lacerations on extremities. c. Red: An 80 y/o female patient with a laceration on the head, altered mental status and respirations of 45 breaths per minute. d. Yellow: A 47 y/o male patient complaining of 7/10 abdominal pain with notable bruising on the abdomen.
Answer B Rationale: The patient in option A is correctly tagged, her agonal breaths and thready pulse indicate a low chance of survival. The patient in option C is correctly tagged because she is a critical patient that cannot wait for care. Her increased respirations and changed LOC indicate that she needs immediate intervention. Option D is correct because the patient is able to verbalize pain and injury, however, will need medical attention as soon as possible. Patient B is incorrectly tagged. He should be labeled with a green tag. He is able to move with a limp and has minimal injury. He would be considered "walking wounded."
The nurse is called from the hospital to assist the emergency medical technicians in a disaster response. The nurse classifies some victims into the "black-tagged" category bases on what assessment findings? SATA. a. Leg fracture b. Massive head trauma c. Abrasions and contusions d. Full-thickness body burns e. High cervical spinal cord injury
Answer B, D, E. Rationale: Black-tagged category patients are those who are expected to die. Patients with massive head trauma. Fill=thickness body burns, and high cervical spinal cord injury are generally expected to die. Victims with leg fractures or abrasions and contusions can be given delayed treatment and are therefore classified as green-tagged victims.
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. A client 3 days post-op total knee replacement complaining of right calf pain with movement c. A 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
Answer B. Rationale: Assessment for possible DVT takes priority and should be reported to the physician. It could evolve to an embolism resulting in stroke, heart attack, or pulmonary embolism. Next - Assess site for client's comfort and prevent complications associated with IV infusion (client A), respiratory rate of client C is within normal range, give client D an antiemetic but is not priority.
The nurse puts a restraint jacket on a patient without the patient's permission and without a physician's order. The nurse could be found guilty of: a. Assault b. Battery c. Invasion of privacy d. An unintentional tort
Answer B. Rationale: Battery is the physical harm of a person. Assault is a threat to a patient. Invasion of privacy would not be applicable in this situation. An unintentional tort is failing to act responsibility (negligence).
Ethical dilemmas often arise over a conflict of opinion. Once the nurse has determined that the dilemma is ethical, a critical first step in negotiating the difference of opinion would be to: A. Consult a professional ethicist to ensure that the steps of the process occur in full B. Gather all relevant information regarding the clinical, social and spiritual aspects of the dilemma C. List the ethical principles that inform the dilemma so that negotiations agree on the language of the discussion D. Ensure that the attending physician has written an order for an ethics consultation to support the ethics process
Answer B. Rationale: Gather all relevant information regarding the clinical, social and spiritual aspects of the dilemma. Rationale: Each step in the processing of an ethical dilemma resembles steps in critical thinking. The nurse begins by gathering information and moves through the assessment, identification of the problem, planning, implementation and evaluation.
For a patient who is experiencing the side effects of radiation therapy, which task would be most appropriate to delegate to the UAP? a. Helping the patient to identify patterns of fatigue b. Recommending participation in a walking program c. Reporting the amount and type of food consumed from the tray d. Checking the skin for redness and irritation after the treatment
Answer C Rationale: The UAP has a scope of practice that allows them to observe the amount that the patient eats and report to the nurse. Assessing the patterns of fatigue and checking the condition of a patient's skin is the responsibility of the Registered Nurse. Recommending participation in a walking program is the initial responsibility of the physician
The charge nurse handed out daily assignments to the nurse, which patient should be seen first? A. A patient who recently had abdominal surgery complaining of right flank pain. B. A patients whose blood pressure is 90/70. C. A patient who had circumoral burns who is now complaining of shortness of breath. D. A patient who is on antihypertensives who is complaining of dizziness.
Answer C Rationale: The airway is compromised from the circumoral burns and should be seen immediately to prevent apnea. Incorrect: A: A patient complaining of right flank pain should be seen, although, airway is the number one priority, B: This patient's blood pressure is alarming and should be seen, but should not come before a patient with a compromised airway, D: Dizziness is a common side effect of antihypertensives and is not alarming
You're making the patient assignments for the next shift. On your unit there are three LPNs, two RNs, and two nursing assistants. Which patients will you assign to the LPNs? Select all that apply: a. A 68 year-old male patient who is expected to be discharged home with IV antibiotic therapy. b. A 25 year-old female patient newly admitted with diabetic ketoacidosis. c. A 75 year-old male patient with dementia who has an ileostomy and scheduled tube feedings. d. A 65 year-old female patient who has an order to remove the Foley catheter
Answer C and D. Rationale: Option A: An RN is the best for this patient because the patient will need discharge teaching AND the nurse will need to teach the patient how to self-administer antibiotics. Option B: This is a new admission and the patient is UNSTABLE. Most patients with DKA (diabetic ketoacidosis) require insulin drips along with close monitoring of the blood glucose levels, which requires critical thinking and interpretation. Options C and D are best for the LPNs: these are standard routine procedures the LPN can perform and these patient cases are stable.
People are knowledgeable about natural disasters within their local regions; however, many have not had to consider the devastation that can be caused by terrorism such as radiological exposures, nuclear blasts, conventional bombings, or agricultural contamination. Identify the correct statement. a. A chemical disaster is an incident involving a natural or deliberate outbreak of a pathogen affecting large numbers of adults and children. b. A biological disaster is a catastrophic event caused by the use of weapons such as guns, bombs, missiles, and grenades. c. A cyber disaster is a catastrophic event affecting large numbers of people and lasting more than a few hours that impacts the ability to use information technology d. A radiological/nuclear disaster is a foreseen and often sudden event with radioactive materials that causes great damage, destruction, and human suffering
Answer C. Rationale: A cyber disaster is a catastrophic event affecting large numbers of people and lasting more than a few hours that impacts the ability to use information technology. A chemical disaster is an unintentional or deliberate release of poisonous vapors/liquids. A biological disaster includes disease epidemics or an incident occurring from deliberate or unintentional release of biological materials. A radiological/nuclear disaster may be an intentional (foreseen) by terrorists or an unintentional (unforeseen) accident within a facility or with a vehicle transporting radioactive materials that expose a region
The nurse has just received report on four patients. Which patient should the nurse assess first? a. A postoperative cholecystectomy patient who is complaining of pain but received an IM injection of Morphine 5 minutes ago. b. A postoperative appendectomy patient who will be discharged in the next few hours. c. A patient with asthma who had difficulty breathing during the prior shift. d. An elderly patient with diabetes who is on the bedpan.
Answer: C. Rationale: Airway, breathing & circulation must always be the priority. In this case, all other patients are stable and this patient may require a breathing treatment or another type of intervention to address their breathing difficulties. If this is not addressed, the patient could deteriorate further and a condition or code may need to be called.
The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? a. Call the police. b. Cut up the photograph and throw it away. c. Call the nursing supervisor and report the occurrence. d. Call the laboratory and ask for the name of the individual who sent the photograph
Answer C. Rationale: Call the nursing supervisor and report the occurrence. Rationale: Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.
When a client is confused, left alone with the side rails down, and the bed is in a high position, the client falls and breaks a hip. What law has been broken? a. Assault b. Battery c. Negligence d. Civil Tort
Answer C. Rationale: Ensuring that the patient is safe in their environment is a part of the standards of basic care for all nurses to follow. Not performing these measures means they are not providing the standard of care for their patient. Negligence is conduct that falls below the standard of care. This patient's injury could have been prevented if the nurse had performed all of these safety measures prior to leaving the patient alone
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 an impalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant? a. Assisting with the intubation b. Placing the defibrillator pads c. Doing chest compressions d. Initiating bag valve mask ventilation
Answer C. Rationale: Performing chest compressions are within the training of a nurse assistant. The use of the bag valve mask requires practice, and usually a respiratory therapist will perform the function. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.
The RN is planning assignments for the day. What is the most appropriate assignment that the RN can delegate to the UAP? a. A client requiring colostomy irrigation b. A client requiring continuous tube feedings initiated c. A client requiring a urine specimen collection d. A client with difficulty swallowing both foods and liquids
Answer C. Rationale: The most appropriate assignment for the UAP would be the client needing urine specimen collections. Colostomy irrigations and tube feedings are invasive procedures - so not performed by the UAP. The client who is have difficulty swallowing foods and liquids should not be given to the UAP because of the risk for aspiration.
A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? a. Call the chaplain to convince the client to receive the blood transfusion. b. Discuss the case with coworkers. c. Notify the primary healthcare provider of the client's refusal of blood products. d. Explain to the client that they will die if they refuse the blood transfusion.
Answer C. Rationale: The nurse serves as an advocate for the client to uphold their wishes. Synthetic blood products are available but must be prescribed by the primary healthcare provider. Therefore, the primary healthcare provider needs to be notified of the client's refusal for blood so alternatives can be considered. The chaplain's role is to offer support, not to convince the client to go against beliefs. It is a Health Insurance Portability and Accountability Act (HIPAA) (Canada: Personal Health Information Protection Act [PHIPA]) violation to discuss the case with coworkers unless they are involved in the care of the client. The nurse should not use threats or fear to coerce the client.
The primary care provider wrote a do-not-resuscitate (DNR) order. The nurse recognizes that which applies in the planning of nursing care for this client? a. The client may no longer make decisions regarding his or her own health care. b. The client and family know that the client will most likely die within the next 48 hours. c. The nurses will continue to implement all treatments focused on comfort and symptom management. d. A DNR order from a previous admission is valid for the current admission
Answer C. Rationale: The nurse will continue to implement all treatments focused on comfort and symptom management. Rationale: A DNR order only controls CPR and similar life-saving treatments. All other care continues as previously ordered. Competent clients can still decide about their own care (including the DNR order.)
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."
Answer C. Rationale: This is the best answer because the nurse is assessing the client's level of knowledge as a result of the discussion with the primary care provider. Based on this assessment, the nurse may initiate other actions (call the primary care provider if the client has any questions)
An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
Answer D. Rationale: The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.
Community stakeholders (local government, fire and rescue workers, hospitals) have been focused on gathering information from a variety of resources, developing collaborative response plans, and preparing for a probable disaster. As nurse managers and leaders, what steps are essential first? a. Engaging acute care facilities to be prepared and have a plan in place only for external disasters b. The Health Insurance Portability and Accountability Act (HIPAA) and The Joint Commission (TJC) require all health care facilities to have detailed all-hazard preparedness plans and to conduct drills internally. c. Establishing an all-hazards preparedness plan to create an all-hazards preparedness task force (AHPTF) that includes knowledge of the national response plan and state and local disaster response plans d. Designing an all-hazards preparedness plan that includes only those in the internal organization
Answer C. Rationale: When engaging acute care facilities to be prepared and have a plan in place, external and internal disasters such as fires and any loss of critical resources should be included. HIPAA and TJC require all health care facilities to have detailed all-hazard preparedness plans and to conduct drills both internally and with community agencies. Establishing an all-hazards preparedness plan to create an AHPTF and local, state, and national response plans is the first step. The AHPTF includes nurses who understand the critical processes for patient care and resource needs for this care. When designing an all-hazards preparedness plan, membership should include both those in the internal organization and those within the surrounding communities. This preparedness assures support from all available resources within the community, volunteer and staff identification, and credentialing procedures, downtime procedures, and accommodations for staff.
A nurse receives report and starts making her plan for the day. Which patient should the nurse see first? a. 90 year old patient with resolving aspiration pneumonia complaining of SOB. b. 60 year old bilateral AKA patient complaining of pain in the legs. c. 35 year old 2 days post op from a colostomy with no stool excretion. d. 44 year old patient on a PCA pump who has reached lock out now showing respirations of 5 breaths per minute
Answer D Rationale: this patient has reached lockout on the PCA pump and is experiencing respiratory depression and must be evaluated immediately.
People are knowledgeable about natural disasters within their local regions; however, many have not had to consider the devastation that can be caused by terrorism such as radiological exposures, nuclear blasts, conventional bombings, or agricultural contamination. Identify the correct statement. a. A chemical disaster is an incident involving a natural or deliberate outbreak of a pathogen affecting large numbers of adults and children. b. A biological disaster is a catastrophic event caused by the use of weapons such as guns, bombs, missiles, and grenades. c. A radiological/nuclear disaster is a foreseen and often sudden event with radioactive materials that causes great damage, destruction, and human suffering. d. A cyber disaster is a catastrophic event affecting large numbers of people and lasting more than a few hours that impacts the ability to use information technology.
Answer D. Rationale: A chemical disaster is an unintentional or deliberate release of poisonous vapors, liquids, or solids that have a toxic effect on people, plants, and animals. A biological disaster includes disease epidemics and insect/animal plaques or an incident occurring from deliberate or unintentional release of biological materials that adversely affect health to those exposed and is not a catastrophic event caused by the use of weapons such as guns, bombs, missiles, and grenades. A radiological/nuclear disaster may be an intentional (foreseen) by terrorists or an unintentional (unforeseen) accident within a facility or with a vehicle transporting radioactive materials that expose a region. The incident is often a sudden event that causes human suffering. A cyber disaster is a catastrophic event affecting large numbers of people and lasting more than a few hours that impacts the ability to use information technology
While caring for the postoperative client following a total laryngectomy with radical neck dissection, the nurse observes that the client is restless and has a respiratory rate of 28 BPM. Which action is the nurse's priority? a. Suction the client's laryngectomy tube b. Apply oxygen by mask at 4 liters per minute c. Elevate the head of the client's bed to 45 degrees d. Assess the client's oxygen saturation level
Answer D. Rationale: Assess the client's oxygen saturation level. A- suction the client's laryngectomy tube - this could disturb the client's healing process and cause harm. B- apply oxygen by mask at 4 liters per minute - if unnecessary, it could harm ABG's. C- elevate the head of the client's bed to 45 degrees - this could disturb the client's healing process and cause harm. D- assess the client's oxygen saturation levels - RN needs to assess before doing anything in order to prevent harm
A registered nurse arrives at work and is told to "float" to the ICU for the day because the ICU is understaffed and needs an additional nurse to care for the clients. The nurse has never worked in the ICU. Which of the following is the most appropriate nursing action. a. Refuse to float in the ICU b. Call the hospital lawyer c. Call the nursing supervisor d. Report to the ICU and identify the tasks that can be safely performed
Answer D. Rationale: Floating is acceptable and legal practice. The nurse floated to a unit and will be given a quick orientation. They will be assigned to care for stable patients or those with conditions similar to her training experience.
The nurse is caring for a 56 year old female who started chemotherapy treatments 3 days ago. Which side effect warrants immediate intervention? A. Nausea & Vomiting B. Loss of appetite C. Fatigue D. Paresthesia
Answer D. Rationale: Paresthesias may indicate swelling and compression of nerves, it is important for early intervention to prevent permanent damage of sensation.
The resources for nurse executives, nurse leaders, or other nurse representatives would include some of the following references, but where should the managers begin to access knowledge about planning for disasters? A. Agency for Healthcare Research and Quality (AHRQ) B. American Hospital Association (AHA) C. Centers for Disease Control and Prevention (CDC) D. Federal Emergency Management Association (FEMA)
Answer is D Rationale: Nurse leaders should start with FEMA resources to collaborate with the community's needs. FEMA primary focuses on disaster and emergency preparedness and how hospitals should respond in these incidents. Answers A, B, and C all provide areas of information regarding emergency preparedness but is not the primary focus.
A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? A. Drainage of a clear fluid from the clients nose B. Withdrawal of the client in response to painful stimuli C. Bruises and minimal edema of the eyelids D. Bleeding around the lacerations
Answer: A Rationale: Option A is the correct answer because clear drainage from the client's nose indicates that there is a leakage of CSF and should be reported to the physician immediately. Option B (Withdrawal of the client in response to painful stimuli) could indicate that his condition is improving. Option C (Bruises and minimal edema of the eyelids) and options D (Bleeding around the lacerations) are expected when lacerations on the face are present.
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? A. Observe how well the patient performs pursed-lip breathing. B. Plan a nursing care regimen that gradually increases activity intolerance. C. Assist the patient with basic activities of daily living. D. Consult with the physical therapy department about reconditioning exercises.
Answer: A Rationale: Option A: Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Options B and D: Planning and consulting require additional education and skills, appropriate to an RN. Option C: Assisting patients with ADLs is more appropriately delegated to a nursing assistant
You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? A. Assisting the patient with oral hygiene B. Observing the patient's response to feedings C. Facilitating expression of grief or anxiety D. Initiating daily weights
Answer: A. Rationale: Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that measurement.
When the nurse described the client as "that nasty old man in 354," the nurse is exhibiting which ethical dilemma? a. Gender bias and ageism b. HIPAA violation c. Beneficence d. Code of ethics violation
Answer: A. Rationale: Stereotyping an "old man" as "nasty" is a gender bias and an ageism issue. The nurse is verbalizing a negative descriptor about the client
The high-pressure alarm on a patient's ventilator goes off. When the nurse enters 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 the nurse take next? a. Reassure the patient that 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.
Answer: B. Rationale: Option B: Manual ventilation of the patient will allow you to deliver a FiO2 of 100% to the patient while you attempt to determine the cause of the high pressure alarm. Options A, C, and D: The patient may need reassurance, suctioning, and/or insertion of oral airway but the first step should be an assessment of the reason for the high-pressure alarm and resolution of hypoxia
The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? A. Administering IV fluids as prescribed by the physician B. Providing straws and offering fluids between meals C. Developing a plan for added fluid intake over 24 hours D. Teaching family members to assist the client with fluid intake
Answer: B. Rationale: UAPs can reinforce additional fluid intake once 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.
Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks the unit secretary has acquired AIDS. She proceeds to tell the staff that the secretary probably contracted the disease from her husband who is supposedly a drug addict. The RN should inform the UAP that making this accusation has violated which legal tort? A. Libel B. Assault C. Slander D. Negligence
Answer: C Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves professional actions that fall below the standard of care for a specific professional group.
A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor? a. Red b. Yellow c. Green d. Black
Answer: C Rationale: Green tags are for patients who have MINOR injuries. If the patient can walk around, they are tagged as green. Sometimes they are referred to as the "walking wounded".
You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first? A. Green B. Yellow C. Red D. Black
Answer: C Rationale: The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The patient is still alive but there is a severe alteration in their breathing, circulation, or mental status that requires immediate medical attention.
Your patient with peptic ulcer disease has the following vital signs: BP 88/42, apical pulse 132, RR 28. You determine the nursing diagnosis for your patient as "altered tissue perfusion r/t decreased circulatory volume." Which intervention should you implement first? a. Notify the laboratory to draw a type and crossmatch. b. Assess the patient's abdomen for tenderness. c. Insert an 18-gauge catheter and infuse lactated Ringer's. d. Check the patient's pulse oximeter reading.
Answer: C. Rationale: Insert an 18-gauge catheter and infuse lactated Ringer's. Notifying the laboratory for a type and crossmatch would be an appropriate intervention since the patient is showing signs of hypovolemia, BUT it is not the first intervention because it would not directly support the patient's circulatory volume. The stem of the question has provided enough assessment data to indicate the patient's problem of hypovolemia, so further assessment data are not needed. The vital signs indicate hypovolemia, which is a life-threatening emergency that requires you to intervene to support the patient's circulatory volume by infusing lactated Ringer's. A pulse oximeter reading would not support the patient's circulatory volume.
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 a severe head injury, 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.
Answer: C. Rationale: There are two situations in which informed consent of an adult client is not needed... (1) During an emergency when delaying treatment for the purpose of obtaining informed consent would result in injury or death of the client. (a) Client is unconscious and has a severe head injury, if not treated it could lead to the death of the patient (2) when the client waives the right to give informed consent or is mentally incapacitated. A would cause will delay emergency treatment, B is inappropriate and D is not the best action because it delays necessary emergency treatment- this would be done after emergency care is given
A nurse is caring for a client with wrist restraints. Which nursing intervention would receive the highest priority regarding the wrist restraints? a. Providing range-of-motion exercises to the wrists b. Removing the restraints periodically per agency guidelines c. Applying lotion to the skin under the restraints d. Assessing color, sensation, and pulses distal to the restraint
Answer: D Rationale: Assessing color, sensation, and pulses distal to the restraint determines the presence of neurovascular compromise that is associated with the use of restraints. All of the other interventions should be implemented, but option D is the priority.
The nurse has received the client assignment for the day. Which client should the nurse care for first? a. The client receiving chemotherapy who is on day 3 of a 5-day regimen and has question about nutrition. b. The client receiving external radiation who has complaints of dryness and itching skin at the treatment area. c. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and pulling at the incision site. d. The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination.
Answer: D Rationale: The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination. The client is neutropenic, having lost their primary defense against infections becoming susceptible to bacterial infections. Painful urination is an indication of a urinary tract infection
You are providing nursing care for a 24-year-old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP? A. Teaching the patient how to secure a clean-catch urine sample B. Assessing the patient's urine for color, odor, and sediment C. Reviewing the nursing care plan and add nursing interventions D. Providing the patient with a clean-catch urine sample container
Answer: D Rationale: Providing the equipment that the patient needs to collect the urine sample is within the scope of practice of a UAP. Teaching, planning, and assessing all require additional education and skill, which is appropriate to the scope of practice of professional nurses.
An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? A. "Oh, really? I will discuss this situation with your son." B. "Let's talk about the ways you can manage your time to prevent this from happening." C. "Do you have any friends who can help you out until you resolve these important issues with your son?" D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."
Answer: D. Rationale: The nurse must report situations related to child or elder abuse. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation.
After a change of shift, you are assigned to care for the following patients. Which patient should 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 IV antibiotics. d. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.
Answer: D. Rationale: The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. Incorrect: A- This is not an urgent issue. B- 90% oxygen saturation is acceptable for a patient with COPD. C- This is not an urgent issue.
The Registered Nurse is caring for a client who underwent a hysterectomy. Which tasks can be delegated to the Unlicensed Assistive Personnel (UAP) to provide quality care to the client? (SATA) a. Record vital signs b. Assisting the client while bathing c. Administering oral medications d. Preparing the care plan for the client e. Administer intravenous antibiotics
Answers A & B Rationale: Tasks within the scope of practice for a UAP include recording vital signs and providing basic hygiene, such as assisting the client with activities of daily life such as bathing. Administering oral medications is under the scope for a LPN and LVN and depending on the state, the RN is responsible for both IV administration of antibiotics and developing the care plan for their patient.
As the registered nurse, which tasks below should you NOT delegate to the LPN? (SATA) A. Performing an assessment on a new admission B. Collecting a urine sample from an indwelling Foley catheter C. Developing a plan of care for a patient who is admitted with Guillain-Barré Syndrome D. Educating a patient about how to monitor for side effects associated with Warfarin E. Auscultating lung and bowel sounds F. Starting a blood transfusion G. Administering IV Morphine 2 mg for pain H. Providing wound care to a stage 3 pressure injury
Answers A, C, D, F, G. Rationale: These are all out of the scope of practice for an LPN. Remember anything that deals with assessments, educating, evaluating, developing a plan of care, IV medications, unstable patients, or invasive/complex procedures where there is unpredictability the RN is responsible for doing it, and these tasks can't be delegated. An LPN can perform a focused assessment by listening to lung or bowel sounds and report the findings to the RN but a comprehensive assessment is done by the RN. In addition, the LPN can perform standard procedures that are predictable on stable patients like wound care for a pressure injury, Foley catheter insertion, obtaining an EKG, obtaining blood glucose level etc.
Which patients below are best assigned to the LPN? Select all that apply. A. A 30-year-old male patient with active GI bleeding that requires multiple blood transfusions B. A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet D. A 55-year-old male patient who reports chest pain and has ST segment elevation on his EKG
Answers: B and C. Rationale: LPNs should be assigned stable patients with predicable outcomes and cases that don't require critical thinking or complex analysis.
The nurse receives change in shift report on four assigned clients. Prioritize the order that the nurse should assess the clients. a. The 47-year-old client two days postoperative who has pain rated at a 2 on a 0 to 10 pain scale b. The 82-year-old client who was unable to void and has a bladder scan showing 300 mL of urine c. The 76-year-old client newly admitted with serum blood urea nitrogen (BUN) of 52 mg/dL d. The 57-year-old client with hypertension who has severe midsternal pain
Order: D, C, B, A. Rationale: D. The 57-year-old client with hypertension who has severe midsternal pain should be assessed first. The client may be experiencing angina and needs immediate intervention. C. The 76-year-old client newly admitted with serum BUN of 52 mg/dL should be assessed second. The elevated BUN could indicate dehydration. B. The 82-year-old client who was unable to void and has a bladder scan showing 300 mL of urine should be the third client assessed; if the client is unable to void, the nurse should assess the client, initiate other measures to promote voiding and, if unsuccessful, contact the HCP; the client may need intermittent urinary catheterization for the bladder emptying. A. The 47-year-old client two days post-op who has pain rater at 2 on a 0-10 scale should be assessed last of the four clients. A pain level of 2 may be acceptable to the client.
