NCLEX Leadership/ Management
The nurse is preparing a deceased client for a cornea harvesting. Which interventions demonstrate an understanding of the recommended procedural steps? Select all that apply.
Close the eyes. Instill prescribed antibiotic eye drops. Raise the head of the bed 30 degrees.
The nurse manager asks the registered nurse (RN) to describe accountability. Which statement by the RN indicates the need for further teaching about the description of accountability?
"Accountability can be delegated."
The registered nurse (RN) attends a nursing conference, and the topic of the discussion is leadership styles. The RN learns that which leadership style is an approach wherein the leader retains all authority and is primarily concerned with task accomplishment?
Autocratic
A client told that bone metastasis has occurred is considering megavitamin and diet therapy in addition to the prescribed medical therapies. The client asks the nurse for an opinion of these therapies. In formulating a response, the nurse incorporates the concept of autonomy. Which response by the nurse respects the client's right to autonomy?
"Considering all of your options for treatment is important. How can I help you learn more about these treatments?"
The registered nurse (RN) is planning the client assignments for the day. Which clients can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply.
1.A client who needs assistance to the bathroom 2.A client who needs to be turned every 2 hours
The nurse is planning care for a client with a diagnosis of acute glomerulonephritis. Which action should the nurse instruct the unlicensed assistive personnel (UAP) to implement in the care of the client?
Remove the water pitcher from the bedside.
Based on a request made by the client's spouse and children, a primary health care provider asks the nurse to discontinue the feeding tube in a client who is in a chronic debilitated and comatose state. The nurse understands the legal basis for carrying out the prescription and first checks the client's record for which documentation?
Authorization by the family to discontinue the treatment
A client with heart failure suddenly develops severe dyspnea and pulmonary edema. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?
Autocratic
The nurse is caring for the client recovering from general anesthesia after having mastectomy surgery. The client's vital signs at 8:00 a.m. are temperature, 98.8° F (37.1° C); heart rate, 78 beats per minute; respirations, 18 breaths per minute; and blood pressure, 95/60 mmHg. The client is alert and oriented. When the nurse checks the client at 10:00 a.m. the client is confused and restless. What is the priority order of the nursing actions? Arrange the actions in the order they should be performed. All options must be used.
Check vital signs. Administer prescribed supplemental oxygen. Have another nurse stay with client. Notify the surgeon. Document all findings.
The nurse is preparing to administer preoperative medication with sedating effects. In what priority order should the nurse implement the actions? Arrange the actions in the order they should be performed. All options must be used.
Identify the client. Verify the surgical procedure and surgical site. Review information with the client about postoperative care. Administer preoperative medication. Put the side rails up and call bell within reach.
The nurse manager is planning to implement needed changes in the method of the documentation system for the nursing unit. Which should be the initial step in the process of change for the nurse manager?
Identify the inefficiency that needs improvement or correction.
A client with a history of hyperparathyroidism and severe osteoporosis is newly hospitalized. The nurse reviews the plan of care for the client and selects which problem as the priority?
Injury
An explosion occurred at an industrial plant, injuring 50 victims. Which victim should the occupational health nurse at the scene determine should be transported to the hospital first?
Victim with singed nasal and facial hair and difficulty breathing
A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
"Why don't you feel like getting up?"
The nurse has received the client assignment for the day. Which client should the nurse plan to assess first?
A client who is 24-hours post-thyroidectomy and reported to have cramping in the legs
Which client could the registered nurse (RN) appropriately assign to the licensed practical nurse (LPN)?
A client who needs medication administered via a gastrostomy tube
The nurse manager is creating a plan of action for the emergency department in the event of an internal fire. What should the nurse manager include in the plan? Select all that apply.
Direct ambulating clients to walk to a safe location. Remove all clients from danger before attempting to extinguish the fire. Move bedridden clients away from the fire area by use of beds or stretchers.
Which prescription written by the primary health care provider for a client diagnosed with pneumonia should the nurse complete first?
Obtain a culture and sensitivity of sputum.
The nurse entering the room of a client who has just returned from surgery for a total laryngectomy and radical neck dissection notes all of these findings. The nurse should address these findings in which priority order? Arrange the actions in the order that they should be addressed. All options must be used.
The client is lying in a lateral position with the head of the bed flat. The client has copious amounts of blood-tinged secretions from the tracheostomy. The Jackson-Pratt drain in the neck wound is closed but not compressed. The urinary drainage tube is clamped, and the client reports the need to urinate.
The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, what would indicate a negative variance?
The presence of dysrhythmias in a client with a myocardial infarction
The registered nurse (RN) is planning the client assignments for the day. Which assignment is the most appropriate assignment for the unlicensed assistive personnel (UAP)?
A client requiring frequent ambulation
The nurse caring for a chronically ill client with a poor prognosis shows an understanding of the basic values that guide the implementation of a living will by asking which questions? Select all that apply.
"Do you feel the need to discuss your end-of-life decisions with your family?" "Can we discuss what will happen if you decide to refuse antibiotics if you get an infection?" "Have you given thought to whether you want cardiopulmonary resuscitation (CPR) measures if your condition worsens?"
During the admission process of a client being admitted for surgery, the client asks the nurse if a living will, prepared 3 years ago, remains in effect. Which response is most appropriate for the nurse to provide the client?
"If it accurately reflects your situation and wishes."
The nurse educator has just finished teaching a course on disaster preparedness to a group of nurses. Which statements by one of the nurses indicate that the teaching has been effective? Select all that apply.
"Nurses test plans by participating in disaster drills." "Nurses play key roles before, during, and after a disaster." "Nurses assist in developing internal and external emergency response plans."
A client tells the nurse that a lawyer has prepared a living will and will be visiting today so that the will can be reviewed and signed. The client asks the nurse to act as a witness to the signing. Which response should the nurse provide to the client?
"The nurse caring for a client cannot serve as a witness to a living will."
The nurse manager is working in a busy emergency department when multiple clients arrive by ambulance. After reviewing client information and with an understanding of the purpose of the forensic nurse examiner (RN-FNE), which clients should the nurse manager request that the RN-FNE evaluate? Select all that apply.
2.A child who was reportedly abused 3.A client who is self-reporting being raped
The nurse working on an adult nursing unit is told to review the client census to determine which clients could be discharged if there are a large number of admissions from a newly declared disaster. The nurse determines that the clients with which medical situations would need to remain hospitalized? Select all that apply.
4.Ongoing ventricular dysrhythmias while receiving procainamide 5.Newly delivered postpartal client with a blood pressure of 146/94 mm Hg and 2 + proteinuria.
The nurse manager is planning the client assignments for the shift. Which client should the nurse assign to an unlicensed assistive personnel (UAP)?
A client on a 24-hour urine collection who is on strict bed rest
The nurse has received the client assignment for the day. Which client should the nurse assess first?
A client with gastritis who has just vomited 500 mL of blood and has a pulse rate of 120 beats per minute
Which plan of care would be appropriate for a victim green tagged during a disaster?
Allow the victim's care to be managed in a delayed fashion.
The nurse in a postanesthesia care unit (PACU) receives a new postoperative client who had general anesthesia. What is the priority order in which the nurse should perform the assessment? Arrange the actions in the order they should be performed. All options must be used.
Assess patency of the airway. Assess vital signs. Assess surgical site. Assess pain level. Assess bladder for distention.
The registered nurse is observing a new nurse begin hemodialysis on a client with chronic kidney disease. The registered nurse intervenes and determines that the new nurse needs further teaching when the new nurse indicates the need for which action?
Covering the connection site with a heavy blanket for vasodilation and warmth
A primary health care provider states to the registered nurse (RN), "I'm in a hurry. Please write a prescription to decrease the client's atenolol to 25 mg daily?" Which is the appropriate nursing action related to this request?
Decline writing the prescription because it is not an emergency situation.
The nurse employed in a community hospital as a unit manager determines that authority in this situation appropriately refers to which area of responsibility?
Having power to approve and/or command an action, or to see that a decision is enforced
A cooling blanket is prescribed for a child with a fever. The nurse caring for the child has never used this type of equipment, and the charge nurse provides instructions and observes the nurse using the cooling blanket. The charge nurse should intervene if the nurse is observed taking which action?
Keeping the child uncovered to assist in reducing the fever
The psychiatric nurse is working with victims and families involved in an explosion at a local industry. What is the priority nursing intervention in the immediate postdisaster period?
Talking to people who are waiting to receive assistance
A client asks the nurse how to become an organ donor. Which information should the nurse include in the discussion?
The client can donate by written consent.
The nurse is performing an admission assessment on a client admitted to the hospital with a diagnosis of fever of unknown origin. Which intervention performed by the nurse is based on the nurse practice act?
Enters the information on the client's record
After being one of only a few passengers to survive an airplane crash, the nurse should anticipate which most likely responses to stress among the surviving individuals? Select all that apply.
1.Difficulty sleeping 2.Feeling vulnerable 3.Feeling blame or guilt 4.Feeling numb or in disbelief
A registered nurse is a preceptor for a new nurse and is observing the new nurse organize the client assignments and prioritize daily tasks. The registered nurse should intervene if the new nurse implements which action?
Documents task completions at the end of the day
A hospital administrator has implemented a change in the method of assigning nurses to client care units. A group of registered nurses is resistant to the change, and the nursing administrator anticipates that the nurses will not facilitate the process of change. Which approach is best for the administrator to take initially in dealing with the resistance?
Encourage the nurses to verbalize feelings regarding the change.
The nurse has delegated several nursing tasks to staff members. What is the nurse's primary responsibility after the delegation of the tasks?
Following up with each staff member regarding the performance of the task
The nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed coworker is assigned to the client. Which action is most appropriate for the nurse to implement initially?
Review the client's medication administration record immediately and discuss the observations with the nursing supervisor.
A community health nurse is working with disaster relief to prevent as much injury and death as possible following a tornado. Which interventions should the nurse expect to be implemented in order to reach this goal? Select all that apply.
1.Organizing counseling 2.Providing support to families 3.Finding safe housing for survivors 4.Securing physical care when needed
The nurse in a rehabilitation center is planning the client assignments for the day. Which client has needs that can be most safely met by the unlicensed assistive personnel (UAP)?
A client on strict bed rest for whom a 24-hour urine specimen is being collected
If the nurse encounters an ethical dilemma, what is the order of priority of the steps involved in processing the dilemma? Arrange the actions in the order that they should be performed. All options must be used.
Gather information relevant to the clinical situation and determine if a true ethical dilemma exists.. Examine and determine own values on the ethical issue. Verbalize the problem or ethical dilemma. Consider possible courses of action. Negotiate the outcome. Evaluate the action.
A nursing student is asked to present a client situation that identifies a standard of nursing care. The nursing student demonstrates a need for further teaching concerning standards of nursing care when selecting which client situation?
Nurse inserts an indwelling urinary catheter before assessing fullness of bladder using a bladder scan.
After receiving the client assignment for the day, which postpartum client should the nurse assess first?
The client with heavy bleeding who had an uncomplicated vaginal birth 2 hours ago
The nurse is working with disaster relief after a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which type of prevention?
The tertiary level of prevention
The nurse caring for a client with a diagnosis of end-stage kidney failure is asked by a family member about advance directives. Which statements should the nurse include when discussing advance directives with the client's family member? Select all that apply.
3.The determination of decisional capacity of a client is usually made by the primary health care provider and family. 4.Living wills are written documents that direct treatment in accordance with a client's wishes in the event of a terminal illness or condition. 5.Under the Patient Self-Determination Act (PSDA), it must be documented in the client's record whether the client has signed an advance directive. 6.For advance directives to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment
