NCLEX- leadership and management

The nurse caring for a client in the intensive care unit reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? 1) Contact the appropriate certification and licensing board 2) Document the exchange in the chart 3) Report the incident to the hospital's legal team $) Report the incident to the state medical board

2) There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets >100,000/mm3 [100 x 109/L]) normalizes within a few days. The second form (platelets <40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate heparin discontinuation. When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor. (Options 1, 3, and 4) It is important to first refer up the nursing hierarchy. Educational objective: The nurse should document and then report objections about a clinician's judgment to the nursing supervisor.

The charge nurse is reviewing clients' medical records on the cardiovascular care unit. Which client care outcomes are appropriate? Select all that apply. 1) client receiving a continuous heparin infusion for a DVT remains free of petechiae or purpura 2) client who had a carotid endarterectomy maintains a HR <100 min and BP > 90/60 mm Hg with no neurological changes 3) client who had a percutaneous coronary intervention maintains a chest pain level of <4 on a scale of 0-10 while at rest 4) client with HTN receiving IV furosemide remains free from muscle cramping in the extremities 5) client with PAD following a femoral-popliteal angioplasty remains free of leg pain during ambulation

1 ,2, 4, 5 Clients receiving IV heparin should maintain therapeutic clotting times, avoid developing embolic events, and remain free from signs of heparin-induced thrombocytopenia (eg, petechiae, purpura) (Option 1). Clients having undergone a carotid endarterectomy, a surgical procedure removing plaque from carotid arteries, would be expected to show no evidence of hemorrhage (eg, hypotension, tachycardia) or neurological impairment (eg, decreased level of consciousness, altered mental status) (Option 2). Clients receiving IV furosemide, a loop diuretic, should maintain adequate blood pressure and avoid developing symptoms of electrolyte imbalance (eg, muscle weakness, cramps, cardiac arrhythmia) (Option 4). A femoral-popliteal angioplasty is a surgical procedure to restore perfusion to the legs of clients with peripheral arterial disease. After the procedure, the client should be able to ambulate without evidence of extremity ischemia (eg, leg pain) (Option 5). (Option 3) A percutaneous coronary intervention (PCI) is a procedure used to restore coronary perfusion to prevent or treat ischemia or infarction. Clients having undergone a PCI would be expected to have no chest pain at rest. Chest pain at rest indicates myocardial ischemia. Educational objective: Clients receiving heparin should remain free from heparin-induced thrombocytopenia. After carotid endarterectomy, clients should remain free from hemorrhage and neurological impairment. Those receiving loop diuretics should maintain electrolytes within normal limits. After a femoral-popliteal angioplasty, clients should be able to ambulate without leg pain. They should have no chest pain at rest after a percutaneous coronary intervention. Copyright © UWorld. All rights reserved.

There has been a major community disaster. Stable clients need to be discharged to make more beds available for the victims. Which clients could be discharged safely? Select all that apply. 1) Dx with endocarditis on antibiox with a PICC line 2) Hx of MS with ataxia and diplopia 3) One day posop from a hemicolectomy 4) Reporting abd pain with coffee ground emesis 5) Taking warfarin with PT time/INR of 2x control value

1, 2, 5 Ataxia and diplopia are expected signs/symptoms of multiple sclerosis. Two times the control value demonstrates that warfarin has reached a therapeutic level. The long-term antibiotic course (and follow-up lab work) can continue at home through the PICC line (Options 1, 2, and 5). (Option 3) Large intestine peristalsis does not return for up to 3-5 days. The client cannot be discharged until able to tolerate oral intake with normal elimination. The client has to at least be passing flatus. (Option 4) Coffee ground emesis indicates upper gastrointestinal bleeding. The etiology and treatment need to be determined before the client is discharged. Educational objective: Those who are stable for discharge include the client with multiple sclerosis with ataxia and diplopia, the client on warfarin (Coumadin) that has reached the therapeutic effect, and the client with a PICC line for a long-term antibiotic course.

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply. 1) 1 UAP repositioning a client who is 8 hours postop total hip replacement 2) 1 UAP using a gait belt to transfer a partial weight-bearing client from the bed to a chair 3) 2 UAPs repositioning a client who is sedated and has been on the left side for 2 hours 4) 2 UAPs using the log-rolling technique to move a client with a cervical collar 5) 3 UAPs using a draw sheet to move a client who weighs 220lb up in bed

1, 4 Repositioning and transferring clients can be delegated to unlicensed assistive personnel (UAP) when it is deemed safe and appropriate. The nurse must provide UAPs with detailed instructions, including when to move the client, which techniques to use, and when to use assistive persons or devices. The nurse must also notify UAPs of any client mobility restrictions. Unstable clients and spinal cord stabilization require the presence of a nurse for repositioning or moving (Option 4). The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is at risk for hip dislocation. A wedge may be needed to maintain abduction; nursing judgment is required (Option 1). To reduce the risk of client and staff injury, safe transfers and repositioning are achieved using the following guidelines: Use a gait/transfer belt to transfer a partially weight-bearing client to a chair (Option 2). Use 2 or more caregivers to reposition clients who are uncooperative or unable to assist (eg, comatose, medicated) (Option 3). Use a full-body sling lift to move/transfer nonparticipating clients. Use 2-3 caregivers to move cooperative clients weighing less than 200 lb (91 kg). Use 3 or more caregivers to move cooperative clients weighing more than 200 lb (91 kg) (Option 5). Educational objective: Client repositioning and transferring can be delegated to unlicensed assistive personnel if it is deemed safe and appropriate. The nurse must provide instructions to maintain client safety and intervene if the task is performed inappropriately or requires nurse involvement (eg, spinal cord stabilization).

Which client should the charge nurse assign to the room closest to the nurses' station? 1) Client with a Salem sump tube to continuous suction who is deaf 2) Client with gastroenteritis and dementia who wanders 3) Client with herpes zoster under airborne isolation precautions 4) Client with sickle cell crisis who requires frequent intravenous opioids

2) The client with dementia and gastroenteritis presents the greatest safety risk, which includes potential for falls and fluid and electrolyte imbalance. This client should be assigned to the room closest to the nurses' station as a confused client requires frequent checks and this allows the staff to respond quickly if necessary. (Option 1) The nurse will instruct the client who is deaf on the proper use of the call system. Staff should be instructed to answer this client's call light immediately. Notes to communicate that there was an immediate response to this client's call should be posted at the nurses' station as well. (Option 3) Meeting the needs of a client in airborne isolation safely is not dependent on proximity of the client's room to the nurse's station. The staff should assess the client with the same frequency even if the client is in the room furthest from the nurses' station. (Option 4) The client requiring frequent intravenous pain medication can rest best in a quiet location that is further away from the nurse's station. Proximity to the nurses' station does not affect the frequency of pain assessment, administration, and assessment of response to analgesia. Educational objective: When assigning rooms, the nurse should consider infection control, physical location, acuity level, and individual client safety needs. Cognitive impairment and fluid and electrolyte disturbances pose the greatest risks to a client's safety.

Which components are used in determining the standards of professional nursing practice? Select all that apply. 1) Care given with good intention to the best of one's ability 2) Clinical practice statements of professional organizations 3) Health care institution's policies and procedures 4) Nurse Practice Act of the state/province/territory 5) Nurse's usual custom and practice

2, 3, 4, Standards of nursing practice and care are universal criteria that are used when determining if appropriate, professional care has been delivered. The definition of this minimum acceptable level of care reflects what reasonable, prudent, and careful nurses would do in specific circumstances. The state or province/territory boards of nursing help to regulate these standards. Sources used to define standard of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, expert consensus, the Nurse Practice Act, and statutes from regulatory organizations (Options 2, 3, and 4). (Option 1) The standard of care includes objective criteria and does not consider intention. Guidelines are used in determining if duties were performed in an appropriate manner. A nurse can have good intentions but still fail to meet the standards of professional nursing practice. (Option 5) Standard of care is determined by objective, third-party authoritative/reasonably reliable sources. Nurses who are suspected of negligence, yet cannot provide documentation of the event in question, can testify about their interpretation of usual custom and practice as it relates to the incident. However, an individual's typical actions are not authoritative in determining the universal standard of nursing care and cannot replace the use of objective, authoritative, and predetermined standards of care. Educational objective: The standards of professional nursing practice and care are defined by what reasonable, prudent nurses would do in specific circumstances. These are based on objective, third-party authoritative sources, including literature, laws (Nurse Practice Act), and professional organizations.

A large-scale community disaster occurs and clients must share hospital rooms due to the rapid influx of new victims. Which room assignments are appropriate in this situation? Select all that apply. 1) 2 clients on contact isolation, one with VRE infection and another with MRSA infection 2) 2 clients with C diff infection, one in the stool and the other in a wound 3) A client in sickle cell disease crisis and a client with streptococcal pneumonia 4) a client who had abd surgery today and a client with universal precautions 5) a young client in Buck's traction with an elderly client with Parkinson's disease

2, 4, 5 When clients must be housed together in less than ideal circumstances, those infected with the same causative pathogens can be placed together. However, a client who is infectious should not be placed with an immunosuppressed client (eg, on steroids/chemotherapy, HIV positive, new post-operative, multiple chronic co-morbidities, splenectomy, diabetes, very young/elderly). Every client in the hospital is on universal precautions; therefore, there should be no concern about placing a vulnerable post-operative client in the same room where standard precautions are being taken for another client. In a disaster setting, clients of different age groups can be placed in the same room together so long as both are stable and noninfectious (even if this is not socially acceptable). (Option 1) Though both clients are on contact isolation, they are infected with different organisms and this places them at risk for cross-infection. (Option 3) By around age 4, clients with sickle cell disease have some level of immunosuppression as their spleens are dysfunctional due to infarctions from the sickling episodes. The spleen then fails to carry out protective phagocytosis, especially to encapsulated bacteria (eg, streptococcus pneumoniae). Educational objective: Clients infected with different organisms cannot be placed together in the same room (due to risk of cross-infection). An infectious client should not be housed with an immunocompromised one.

The nurse is providing handoff-of-care report to the oncoming nurse for a client admitted with pneumonia that morning. Which information is most important for the nurse to communicate about the client during handoff report? 1) Chest xray showed lung infiltrates, WBC count is 14,000/mm3 2) Client's spouse was acting rudely toward the nurse earlier 3) Current respirations are 24/min, pulse ox is 93% on 2L/min 4) Intravenous line is infusing with no signs of infiltration

3) Current respiratory status is essential to include in handoff report, as it is objective information related to the client's current condition. Information communicated during report should allow the oncoming nurse to prioritize care and obtain baseline measurements of the client's current status and response to treatment. It is especially important to include information that may not be documented in the medical record. Respiratory status can change rapidly, and the most current measurements may not be documented, as vital signs are often documented every 4, 8, or 12 hours (Option 3). Handoff report typically includes: Client's name, location, age, gender, health care provider, and diagnoses Client's current baseline measurements, treatment plan, goals, and response to treatment Priority and outstanding tasks and changes from previous days (Option 1) Lung infiltrates and elevated WBC count are expected findings with pneumonia and are found in the medical record. Diagnostic findings are significant if there is an ongoing trend, but isolated, expected results are not as helpful in planning care. (Option 2) Personal opinions are not pertinent to providing care. (Option 4) The client's IV site is assumed to be patent without complication, or the offgoing nurse would have changed it. The oncoming nurse should make an individual assessment. Educational objective: Handoff report should include objective information related to the client's current condition. It is especially important to include baseline measurements that may not be documented in the medical record (eg, current respiratory status) so that the oncoming nurse can prioritize care.

The health care provider gives the preoperative nurse a signed consent form and walks away rapidly. The client turns to the nurse and states, "I don't know what is going on. Why do I need surgery?" What is the most appropriate action? 1) call the nursing supervisor 2) call the OR scheduler and cancel the surgery 3) page the HCP and request clarification on behalf of the client 4) report the incident to hospital administration

3) Informed consent requires that the health care provider performing the procedure explain everything to the client's satisfaction (within reason). Signed consent may be witnessed by the nurse. If the client does not fully understand informed consent, the nurse must notify the health care provider or refer up the chain of nursing command. The nurse is not responsible for verifying that the client understands the procedure and its respective risks. (Option 1) This would be appropriate if the health care provider refuses to talk to the client. (Option 2) This is not the nurse's responsibility; this request would have to be relayed up the chain of nursing command. (Option 4) This is premature; the incident is isolated and not all facts are known. Educational objective: Clients may not consent to an invasive procedure without being informed of the clinical reasoning, consequences, and possible complications.

A Native American client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on the client. Which of the following is the best action by the nurse? 1) Explain that the client's depression is being tx with meds 2) explain that the client's depression will not be relieved by a ritual 3) Plan a meeting with the HCP, family, nurse, and med healer to make arrangements for the ceremony 4) Tell the family that such practices are not allowed in the hospital

3) The medicine healer, or shaman, is an important component of Native American culture and is often consulted by both clients and HCPs when a client is ill or hospitalized. The medicine healer uses a variety of practices, including herbs, plants and roots, singing, and healing ceremonies. The medicine healer needs to be included in this client's treatment. Making arrangements for the healing ritual gives credibility and respect to the client's cultural beliefs and ensures that the client's spiritual needs will be met. In providing culturally sensitive care, the nurse needs to recognize and be tolerant of various practices associated with beliefs that are different from those of traditional Western medicine. Denying the medicine healer the opportunity to perform a ritual could interfere with the client's response to therapy. (Option 1) Although it may be true that the client's depression is being treated with antidepressants, the medications do not meet the client's spiritual needs. (Option 2) This response demeans the client's beliefs and does not acknowledge the importance of the medicine healer to the client's health. (Option 4) Allowances and accommodations should be made by health care facilities to ensure that clients' spiritual needs are met. Educational objective: Medicine healers, or shamans, are an important component of Native American and other cultural groups. Allowing medicine healers to perform rituals and ceremonies will ensure that clients' spiritual needs are met and may contribute to the healing process. The nurse needs to recognize and be tolerant of health practices and beliefs that are different from those of traditional Western medicine.

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first? 1) Client in neurogenic shock from a spinal cord injury, with pulse of 56/min, BP of 120/60 mm Hg, and warm and pink skin 2) Client with a concussion from closed-head injury d/t fall, Glasgow Coma Scale score of 15, headache, and memory loss 3) Client with a subdural hematoma, pulse of 48/min, BP of 190/90 mm Hg, and a pupil that reacts slowly to light 4) Client with central diabetes insipidus from a head injury, hypernatremia, and UO of 210 mL/hour

3) A subdural hematoma is caused by bleeding into the subdural space and is the result of blunt force head trauma. It is life-threatening, as increased pressure from the hematoma on the brain can lead to decreased cerebral perfusion and herniation (mid-line shift). Assessing for signs of increased intracranial pressure, including change in level of consciousness, Cushing triad (hypertension, bradycardia, and irregular respirations), ipsilateral pupil dilation, headache, and vomiting, is critical as surgery to evacuate the hematoma and relieve the pressure may be necessary. (Option 1) Manifestations of neurogenic shock include hypotension and bradycardia. Although the client has bradycardia and requires monitoring, the client is normotensive and has normal skin color and temperature, which indicate adequate perfusion. (Option 2) Headache, transient change in level of consciousness, and inability to remember the injury (retrograde amnesia) are expected manifestations of a concussion. The Glasgow Coma Scale score of 15 (range: 3-15) indicates complete orientation. (Option 4) Central diabetes insipidus results from head trauma. Damage to the hypothalamus or pituitary gland leads to decreased antidiuretic hormone secretion, resulting in increased serum osmolality (>295 mOsmol/kg [295 mmol/kg]). Treatment is necessary, but polyuria (>200 mL/hr) and hypernatremia (sodium >145 mEq/L [145 mmol/L]) due to dehydration are expected manifestations. Educational objective: A subdural hematoma is caused by bleeding into the subdural space outside the brain. Surgical evacuation of the hematoma may be necessary to relieve the pressure on the brain, as increased intracranial pressure can lead to decreased cerebral perfusion, herniation (mid-line shift), and death.

A client is receiving several adjunctive professional therapies while rehabilitating after a stroke. Which client statements indicate an understanding of the services? Select all that apply. 1) OT will help me to learn how to properly use my walker. 2) PT will help me learn how to dress myself again. 3) Social services can help me find resources for affording my meds. 4) Speech therapy will teach me how to eat my meals properly. 5) Wound care will teach me how to properly dress this wound on my knee.

3, 4, 5 Several adjunctive professional services assist clients in the post-acute phase of their illness as part of an overall interdisciplinary team. Speech therapy focuses on speech and communication but also on swallowing/eating issues (Option 4). A client with a stroke will need to be evaluated for any aspiration risks and taught how to minimize those risks (eg, chin-down positioning, chewing on the non-affected side of the mouth). Social workers assist with developing coping skills, securing adequate financial resources or housing, and making referrals to volunteer organizations (Option 3). Wound care is a resource for assessing and planning the optimal care of any wound (Option 5). (Option 1) Occupational therapy emphasizes the skills necessary for activities of daily living (eg, dressing, bathing, cognitive or perception issues); however, walker training is performed by a physical therapist. An overly broad generalization is that occupational therapy is for "above the waist." (Option 2) Physical therapy focuses on mobility, ambulation, ability to transfer, and use of related equipment. An overly broad generalization is that physical therapy is for "below the waist." Dressing skills would be taught via occupational therapy. Educational objective: Some of the adjunctive professional services in post-acute care include wound care (eg, assessing/planning wound treatment), speech therapy (eg, communicating, swallowing, eating), social work (eg, coping, connecting to resources), physical therapy (eg, mobility, ambulating, using equipment), and occupational therapy (eg, activities of daily living).

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first? 1) Client with charred, leathery skin over entire back, chest, and legs 2) Client with cool skin, shivering from sitting in water until rescued 3) Client with diabetes who was unable to take prescribed insulin today 4) Client with high-pitched, crowing inspiratory respirations

4) Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with stridor (eg, high-pitched, crowing inspiratory respirations), which typically occurs from constricted or blocked upper airways, is at risk for impending respiratory failure due to a compromised airway. This client should be classified as emergent, requiring immediate treatment and possibly prophylactic intubation (Option 4). (Option 1) Using the rule of nines, clients with full-thickness burns to the chest, back, and legs are suspected to have at least 72% total body surface area burns and should be classified as expectant (black tag). (Option 2) Clients with wet clothing or cold water immersion are at risk for hypothermia but can be easily self-managed by provision of warm, dry blankets; this client should be classified as nonurgent (green tag). Untreated hypothermia may lead to decreased cerebral metabolism, dysrhythmias, and coagulopathies. (Option 3) Clients with diabetes mellitus who are unable to receive insulin may develop hyperglycemia, which is unlikely to cause rapid deterioration. This client can perform self-care and should be classified as nonurgent (green tag). Educational objective: During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that categorizes them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant).

The charge nurse on the medical surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? 1) Room 1 - Client with diabetes mellitus and CKD who is on hemodialysis and has a serum glucose level of 265 mg/dL 2) Room 2- Client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 3) Room 3- Client with cellulitis of the leg due to a spider bite who has a WBC count of 13,000/mm3 4) Room 4 - Client with severe epitaxis d/t traumatic nasal fracture who has a platelet count of 85,000/mm3

4) The best option is room 4 with the client who has severe epistaxis and decreased platelet count (normal 150,000-400,000/mm3 [150-400 x 109/L]) as this does not place the immediate post-operative client at increased risk for infection. (Options 1, 2, and 3) The clients in these rooms place the postoperative client at increased risk for infection: Room 1: A client with diabetes mellitus and advanced chronic kidney disease may have infectious complications due to increased susceptibility to infection resulting from an altered immune response and decreased leukocyte function due to hyperglycemia. In addition, hemodialysis increases the risk for infection due to invasive lines and catheters. Room 2: A low CD4+ cell count (<500/mm3 [0.5 x 109/L], normal is 500-1,200/mm3 [0.5-1.2 x 109/L]) in a client with chronic HIV infection indicates disease progression. It can also indicate progression of asymptomatic early infections to more advanced symptomatic infections. Room 3: The client with cellulitis and an increased white blood cell count (>11,000/mm3 [11.0 x 109/L]) has an infection. Educational objective: An immediate post-operative client should not be assigned a bed in a room with a client who is contagious or potentially infected as this poses an increased risk for infection.

During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give? 1) encourage the night nurse to provide UAP with additional training 2) indicate that it is the night nurse's job to deal with staff problems 3) remind the night nurse that the UAP is doing the best job the UAP can 4) Suggest that the night nurse discuss concerns with the nurse manager

4) Incompetency is a concern for client safety and quality care. The nurse manager is responsible for hiring/firing and setting up additional training times or experiences for staff. The situation should be discussed with the person who has 24/7 responsibility for the unit so that an appropriate response can be given to the night nurse's perceptions (Option 4). (Option 1) The night nurse can provide task-specific instructions/training, but incompetence implies a global dysfunction beyond minor, on-the-job, intermittent instructions. In addition, other factors could be involved that may be influencing the UAP's behavior, such as personal issues or impairment from substance abuse. It is best to discuss this situation with a higher authority to determine the best approach. (Option 2) This response is something the night nurse knows. The need is to decide the next action. The scope of this problem is probably beyond the night nurse's responsibility and authority. (Option 3) This response may be true. However, the bottom line is finding out if the UAP's performance is of adequate quality and safe for clients. The amount of effort that the caregiver is expending is not the bottom line. Educational objective: When a caregiver's performance is below the standard of care needed to provide safe and quality care to clients, the appropriate authority should be notified so that the situation can be handled.