NCLEX QUESTIONS

The case manager is arranging a planning meeting for the care of a client diagnosed with chronic obstructive pulmonary disease (COPD). Who should be included in the meeting? Select all that apply 1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist 6. Occupational therapist

1,2,3,4,5

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the nurse to assign to the LPN/VN? Select all that apply 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin

1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM -These are stable clients that can be assigned to the LPN. LPN can provide meds for pain management. Since the postop client is not requiring frequent assessment and is considered stable at this point, the rn can assing the lpn to care for this client. The client having surgery in the AM is stable and will require predictable preop care the evening prior to surgery, so the LPN can care for this client as well.

A client with leukemia receiving high dose chemotherapy is being evaluated for the development of tumor lysis syndrome. Which lab value should the nurse recognize as being a hallmark sign of the tumor lysis syndrome? Select all that apply 1. Thrombocytopenia 2. Hyperkalemia 3. Hypocalcemia 4. Hyperuricemia 5. Hypomagnesemia 6. Hyperphosphatemia

2,3,4,6 When the cells are destroyed or lyse form chemo, there is a release of potassium and phosphates from the cells. Therefore, hyperkalemia and hyperphosphatemia are direct results of the cellular destruction. Purine are also released during cellular destruction. The purines are metabolized and converted to uric acid, which leads to hyperuricemia. So why is hypocalcemia correct? Do you remember that phosphorus and calcium have inverse relationship? So, if the phosphorus is high, the calcium will be low. That is why the client will have hypocalcemia.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 1. Encourage client to express grief related to loss of independence. 2. Irrigate a client's ear canal. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 4. Show client who has conjunctivitis how to clean the eyes.

3

Which tasks can the RN delegate to an unlicensed assistive personnel (UAP) when caring for a client who has had a stroke and is being rehabilitated? Select all that apply 1. Assess a client's ability to swallow. 2. Develop a plan of care for hygiene needs. 3. Assist the client using a walker. 4. Calculating the intake and output. 5. Encourage and assist the client with the use of a hairbrush on the affected side. 6. Teach the family about the need to prevent pressure ulcers.

3,4,5

Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply 1. Demonstrate post operative exercises. 2. Reposition the transcutaneous electrical nerve stimulation (TENS) unit. 3. Empty the indwelling catheter bag. 4. Assist a client with position change every 2 hours. 5. Apply anti-embolism stockings.

3,4,5 It is whithin the role of an UAP to empty the indwelling catheter back, assist with position change and apply anti-embolism stockings. The nurse should confirm that these tasks have been done but the are safe to delegate to the UAP.

The nurse is planning care for a client admitted with Alzheimer's Disease. What interventions can the nurse delegate to the LPN/VN? Select all that apply 1. Teach caregivers memory enhancement aids. 2. Evaluate client's safety risk factors. 3. Make referrals to community services. 4. Determine caregiver's stress level and coping strategies. 5. Monitor for behavioral changes. 6. Check environment for potential safety hazards.

5, 6

A nurse has arrived late to work twice in the last week. What should be the nurse manager's first action?

Ask the nurse the reason for being tardy The first action should be discussing the tardiness with the nurse. There may be a situation that is impacting the nurse's ability to be on time. This will allow the nurse to explain the tardiness. The nurse manage may have to consider alternate scheduling for the nurse.

The unlicensed assistive personnel is assisting a client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention by the nurse?

Holds chest drainage unit CDU at the level of the chest The drainage system should be held below the level of the chest to promote drainage and prevent backward flow of drainage back into the pleural space.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Check client's bony prominences for redness. 2. Monitor client need for suctioning hourly. 3. Explain how to collect 24 hour urine to client. 4. Take a tympanic temperature on client every two hours. 5. Perform postural drainage and chest physiotherapy on client. 6. Report client's pulse oximetry reading every hour.

Take a tympanic temperature on client every two hours Report client's pulse ox reading every hour.