Papanikolla - NCLEX Management of Care
The nurse on the cardiac unit recognizes which as the primary goal of managed care? 1. Cost containment 2. Quality of client care 3. Ethical decision-making 4. Teaching clients self-management skills
Cost containment
The nurse reporting suspected child abuse is legally operating under which concept? 1. Good Samaritan 2. Duty to Disclosure 3. Discretionary Powers 4. Expert Witness
Duty to Disclosure
A series of inservice on team development are being held for nurse managers at a teaching hospital by the staff development department. The educator has just reviewed the concepts of group process roles and identified several of them by name. One of the managers asks, "Could you please explain what exactly is meant by the gatekeeper role?" Which of the following responses by the educator is best? 1. "The gatekeeper decides who is to attend a meeting and who is not." 2. "The gatekeeper ensures that everyone has an opportunity to speak." 3. "The gatekeeper makes certain that the group starts and ends on time." 4. "The gatekeeper responds to interruptions from outside forces."
"The gatekeeper ensures that everyone has an opportunity to speak."
The nurse reviews the client care given by another RN to a group of psychiatric patients. The nurse knows this is which type of review? 1. Peer review 2. Quality review 3. Performance appraisal 4. Risk review
Peer review
Which of the following client statements about advance directives MOST concerns the nurse on the medical surgical unit? 1. "My living will is all made out and secure in my safe deposit box." 2. "I can change my durable power or attorney at any time." 3. "My friends think I am tempting fate by having advance directives, but I do not care." 4. "I find the thought of my own death or incapacitation to be quite scary."
"My living will is all made out and secure in my safe deposit box."
The nurse is seeing patients in the adolescent psychiatric clinic. Which of the following patients should the nurse see FIRST? 1. A 13-year-old with complaints of impulsivity and poor attention span 2. A 14-year-old who often loses his temper and argues with his teachers 3. A 15-year-old who wants to be a model and only drinks water and eats vegetables 4. A 16-year-old who bullies, threatens, and intimidates others and initiates physical fights
A 15-year-old who wants to be a model and only drinks water and eats vegetables
The nurse recruiter for a hospital addresses senior nursing students attending an open house in the facility. The recruiter states an advantage of working at the institution is they have recently implemented a clinical ladder system. A student asks what that means. Which is the BEST response by the recruiter? 1. "A clinical ladder allows the nurse to stay at the bedside and still progress in the profession." 2. "A clinical ladder helps get supplies, medications, and lab samples up and down quickly to their destination." 3. "A clinical ladder provides each client with a customized step-by-step approach to managing illness." 4. "A clinical ladder provides a structure to enable a nurse to progress toward becoming a physician."
"A clinical ladder allows the nurse to stay at the bedside and still progress in the profession."
During the admission interview of a client admitted for cardiac surgery, the nurse inquires about the existence of advance directives, using the terms "living will" and "durable power of attorney for healthcare." The client becomes upset and shouts, "I do not need any advance directives. I already have a will and an attorney who helps me with everything. Besides, I am not going to die!" Which response by the nurse is BEST? 1. "Do not get angry with me. I am only trying to help!" 2. "A regular will and attorney do not cover healthcare situations, including if you cannot, even temporarily, make your wishes known." 3. "You have to have advance directives in order to be treated here." 4. "A lot of people feel the way you do, but they get over it and sign the forms; they tell me later that they are glad they did it."
"A regular will and attorney do not cover healthcare situations including if you cannot, even temporarily, make your wishes known."
The charge nurse is having difficulty making an appropriate assignment for the nursing team. Which assessment by the supervisor will help the charge nurse making assignment for the day shift? 1. "Describe the knowledge and skill level of each member of your team." 2. "Do you know which assignment each staff member prefers?" 3. "How long has each staff member been employed on the unit?" 4. "Do you know if any staff members are working overtime today?"
"Describe the knowledge and skill level of each member of your team."
The community health nurse plans visits for the day. Which of the following patients should the nurse see FIRST? 1. A 5-year-old male experiencing hyperactivity and impulsivity for two weeks 2. A 13-year-old female truant from school for three days 3. A 13-year-old female vomiting every day for the last three months because she wants to lose weight for the summer 4. A 25-year-old who drinks alcohol every day and is unable to control the amount of alcohol he ingests
A 13-year-old female vomiting every day for the last three months because she wants to lose weight for the summer
The nurse is seeing patients in the psychiatric clinic. Which of the following patients should the nurse see FIRST? 1. A 15-year-old male brought in by police because he threatened to jump off a bridge and has access to a gun 2. A 20-year-old female who lost 2 lb this week and only eats two meals a day 3. A 45-year-old male with a history of depression who states he is out of Prozac 4. A 75-year-old male whose wife passed away two weeks ago and is experiencing insomnia and irritability
A 15-year-old male brought in by police because he threatened to jump off a bridge and has access to a gun
What is the primary focus of the NCLEX-RN? 1. Performance appraisal 2. Evaluation of nursing schools 3. Assessment of minimum competency 4. Measurement of quality client care
Assessment of minimum competency
After receiving the night shift's report, the nurse plans assignments for the day. Which client should the nurse see FIRST? 1. A 17-year-old who took 10 methylphenidate and has a BP of 160/100 2. A 25-year-old who requires a metered-dose inhaler 3. A 30-year-old with a short arm cast on the left arm 4. A 40-year-old diagnosed with hypothyroidism requiring TSH level
A 17-year-old who took 10 methylphenidate and has a BP of 160/100
Clients from a plane crash are transferred to the hospital. The nurse performs triage in the emergency department. Which client should the nurse see FIRST? 1. A 75-year-old with a fracture to the clavicle 2. A 20-year-old with burns to the chest and face area 3. A 10-year-old with an elbow dislocation 4. A 3-year-old with a hip dislocation
A 20-year-old with burns to the chest and face area
Four clients from a house fire are transferred to the emergency department. Which client will the nurse see FIRST? 1. An 18-year-old reporting anxiety and palpitations 2. A 20-year-old with full thickness burns to the face and chest area 3. A 45-year-old diagnosed with a fracture of the right hip 4. A 50-year-old with a superficial partial thickness burn to the hands
A 20-year-old with full thickness burns to the face and chest area
A psychiatric nurse is presented with a group of patients in the ER. Which of the following patients requires IMMEDIATE attention? 1. A 24-year-old male who failed medical school and says, "My pain will be over soon." 2. A 30-year-old female who is unable to talk in front of other people due to symptoms of anxiety 3. A 45-year-old male who hears voices telling him to harm others 4. A 50-year-old male who is anxious after witnessing a murder.
A 24-year-old male who failed medical school and says, "My pain will be over soon."
The nurse is seeing clients in the gastrointestinal clinic. Which client should the nurse see FIRST? 1. A 50-year-old diagnosed with irritable bowel syndrome reporting cramping and loose stools 2. A 25-year-old reporting not having a bowel movement in two days 3. An 8-year-old diagnosed with gastroenteritis who had five diarrheal stools in the last three days 4. A 3-week-old infant experiencing projectile vomiting and irritability
A 3-week-old infant experiencing projectile vomiting and irritability
The nurse cares for clients in a gynecological clinic. Which of the following clients should the nurse see FIRST? 1. A 60-year-old female complaining of dry vaginal wall and painful intercourse 2. A 35-year-old female who had a hysterosalpingogram and is experiencing tachycardia and has a generalized rash 3. A 30-year-old female preparing for a cervical biopsy 4. A 25-year-old female scheduled for a Pap smear
A 35-year-old female who had a hysterosalpingogram and is experiencing tachycardia and has a generalized rash
The pediatric community health nurse plans visits for the day. Which client will the nurse see first? 1. A 10-year-old with a blood lead level of 9 2. An 8-year-old who is aggressive toward siblings when angry 3. A 6-year-old with elevated temperature, cough, and fine crackles 4. An infant who had a pyloromyotomy 4 weeks ago
A 6-year-old with elevated temperature, cough, and fine crackles
Children from a school bus accident are transferred to the hospital. The nurse triages in the emergency department. Which child should the nurse see FIRST? 1. An 8-year-old with a superficial burn to the arm 2. A 7-year-old with burns on 10% of the total body surface area 3. A 6-year-old with small lacerations to the arms and legs 4. A 5-year-old reporting elbow pain
A 7-year-old with burns on 10% of the total body surface area
After receiving the night shift's report, the nurse plans assignments for the day on the Endocrinology Unit. Which client should the nurse see FIRST? 1. A 25-year-old requiring a fasting blood glucose test prior to breakfast 2. A 30-year-old requiring a urine test for ketone bodies 3. A 40-year-old being discharged this afternoon 4. A 70-year-old with a fasting blood glucose of 517 mg/dL
A 70-year-old with a fasting blood glucose of 517 mg/dL
The community health nurse plans visits for the day. Which client will the nurse see FIRST? 1. A 30-year-old diagnosed with type 2 diabetes reporting GI upset after taking chlorpropamide 2. A 45-year-old reporting vomiting after chemotherapy 3. A 62-year-old with a tonometer reading of 21 mm Hg 4. A 76-year-old with a laryngectomy reporting a greenish-yellow discharge
A 76-year-old with a laryngectomy reporting a greenish-yellow discharge
The nurse is seeing clients in the pediatric clinic. Which of the following clients should the nurse see FIRST? 1. A 9-month-old infant with failure to gain weight a blood lead level of 70 2. A preschool child who fears bodily mutilation 3. A 6-year-old who has repeated involuntary urination at night 4. A 7-year-old with a persistent fear of attending school
A 9-month-old infant with failure to gain weight and a blood lead level of 70
The nurse is seeing patients in the pediatric clinic. Which of the following patients should the nurse see FIRST? 1. A 5-year-old diagnosed with autistic disorder demonstrating finger flapping 2. A 6-year-old who has enuresis and often urinates in his underwear 3. A 7-year-old who si shy and has difficulty reading 4. A 9-year-old who has used a weapon against his mother and caused physical harm to others
A 9-year-old who has used a weapon against his mother and caused physical harm to others
An RN from the psychiatric unit is reassigned to the pediatric unit. Which client assignment is MOST appropriate for this nurse? 1. A child diagnosed with type 1 diabetes admitted with a blood glucose of 370 mg/dL reporting thirst and frequent urination 2. A child diagnosed with hemophilia requiring discharge instruction about appropriate and safe sports 3. A child experiencing separation anxiety who wants to stay home with parent instead of going to school 4. A child with a newly diagnosed brain tumor reporting headaches and left-sided-weakness
A child experiencing separation anxiety who wants to stay home with parent instead of going to school
The nursing team caring for clients on the pediatric unit consists of two RNs, two LPNs, and two nursing assistive personnel. Which client does the nurse assign to the LPN? 1. A child admitted with asthma 2. A child in a balanced suspension traction for a fractured left femur 3. A child admitted for intestinal bleeding 4. A child admitted for taking a grandparent's hypertensive medication
A child in a balanced suspension traction for a fractured left femur
The nurse describes the nurse manager's style of leadership. The nurse states, "My nurse manager involves us in making decisions about client care." The nurse is describing which leadership style? 1. Autocratic 2. Laissez-faire 3. Democratic 4. Situational
Democratic
The nursing team caring for clients on the pediatric unit consists of one RN, two LPNs, and three nursing assistive personnel. Which client does the nurse assign to the nursing assistive personnel? 1. A child who needs help socializing with other children 2. A child requiring an 0800 insulin injection 3. A child with a blood lead level of 70 requiring calcium disodium edentate 4. A child reporting abdominal tenderness in the right lower quadrant
A child who needs help socializing with other children
The nurse cares for clients in the child psychiatric unit. Which client should the nurse see FIRST? 1. A child with auditory hallucinations 2. A child expressing worry about leaving the parent to go to school 3. A child receiving haloperidol experiencing blurry vision and dry mouth 4. A child with a lithium level of 0.5 mEq/L
A child with auditory hallucinations
The nursing team consists of an RN, two LPNs, and two nursing assistive personnel. It is MOST appropriate for the nurse to care for which client? 1. A client with right-sided weakness requiring assistance with morning care 2. A client requiring administration of digoxin and furosemide via an NG tube 3. A client whose adult child is upset because the client is diagnosed with terminal cancer 4. A client 24 hours after a laminectomy with spinal fusion having difficulty voiding
A client 24 hours after a laminectomy with spinal fusion having difficulty voiding
An RN has received report and assesses the clients on the unit. It is MOST important for the RN to assign which client to the LPN? 1. A client newly admitted with a diagnosis of myocardial infarction 2. A client with a diagnosis of heart failure who expresses frequent suicidal thoughts 3. A client diagnosed with full-thickness burns covering 40% of the body 4. A client diagnosed with COPD who requires ambulation twice during the evening
A client diagnosed with COPD who requires ambulation twice during the evening
The RN from the pediatric unit is assigned to the psychiatric unit. Which client assignment is the most appropriate for the reassigned nurse? 1. A psychotic client who hears the devil saying to kill self. 2. A suicidal client who had a plan to jump off the bridge today. 3. A client diagnosed with depression with a decreased appetite. 4. An adolescent who vomited every day for three months because of wanting to be thin.
A client diagnosed with depression with a decreased appetite.
The nurse is seeing clients in the medical-surgical unit. Which client will the nurse see FIRST? 1. A client diagnosed with heart failure who received 800 mL of IV fluids in 2 hours 2. A client diagnosed with lung cancer with a blood calcium level op 12.5 3. A client diagnosed with hypertension requiring a 0900 dose of captopril 4. A client postop after a laminectomy requiring supervision when ambulating
A client diagnosed with heart failure who received 800 mL of IV fluids in 2 hours
After receiving the night shift's report, the nurse plans assignments for the day on the Pediatric Unit. Which client will the nurse see FIRST? 1. A client diagnosed with leukemia reporting fatigue 2. A client diagnosed with Wilms' tumor reporting thirst 3. A client diagnosed with hemophilia reporting joint pain 4. A client diagnosed with gastroesophageal reflux reporting abdominal pain
A client diagnosed with hemophilia reporting joint pain
Four clients in the ER are complaining of side effects from their medication. Which of the following clients should the nurse see FIRST? 1. A client receiving clozapine and experiencing flu-like symptoms 2. A client receiving valproic acid and experiencing tremors 3. A client receiving lorazepam and experiencing abdominal discomfort 4. A client receiving methylphenidate who lost 5 lb in 4 weeks
A client receiving clozapine and experiencing flu-like symptoms
The nurse cares for clients in the psychiatric emergency department. Which client will the nurse see FIRST? 1. A client receiving haloperidol experiencing an oculogyric crisis 2. A client receiving thioridazine experiencing akathisia 3. A client receiving risperidone experiencing blurry vision 4. A client receiving fluphenazine experiencing sedation
A client receiving haloperidol experiencing an oculogyric crisis
An RN receives the assignment for day shift. Which client is appropriate for the nurse to delegate to an LPN with 30 years of experience? 1. A client reporting chest pain and dyspnea 2. A client with an abdominal mass that is firm and deep and confined to one side 3. A client reporting polyuria and polydipsia 4. A client three days postop requiring a dressing change
A client three days postop requiring a dressing change
Ten clients from a motor vehicle accident are transferred to the hospital. The nurse triages in the emergency department. Which client should the nurse see FIRST? 1. A client with ecchymosis and lacerations to the facial area 2. A client reporting shortness of breath and pressure in the chest 3. A client with a BP of 90/60 and apical pulse of 120 bpm 4. A client reporting dizziness and nervousness
A client with a BP of 90/60 and apical pulse of 120 bpm
Four injured firefighters are transferred to the hospital. The nurse performs triage in the emergency department. Which client will the nurse see FIRST? 1. A firefighter diagnosed with carbon monoxide poisoning 2. A firefighter diagnosed with a superficial partial thickness burn to the hands 3. A firefighter diagnosed with anxiety and having palpitations 4. A firefighter diagnosed with lacerations to the right side of the face and ear
A firefighter diagnosed with carbon monoxide poisoning
The community health maternity nurse plans visits for the day. Which client should the nurse see FIRST? 1. A newborn who had an Apgar score of 8 and 9 2. A newborn with telangiectatic nevi 3. A newborn with pallor 4. A newborn with a blood glucose of 60
A newborn with pallor
Student nurses discuss characteristics of good documentation. The student nurses identify which of the following adheres to the legal guideline for appropriate documentation? 1. A nurse leaves blank lines in the nurse's notes so the previous shift can add to the charting 2. A nurse utilizes correction fluid to erase a mistake made when charting 3. A nurse documents changes to the patient's condition 4. A nurse charts "physician accidentally ordered incorrect medication" after seeking clarification of the order
A nurse documents changes to the patient's condition
The nurse collapses minutes after putting on latex gloves, and the cardiac team successfully resuscitates the nurse. The nurse manager discusses that certain workers may be at greater risk for latex allergies than others. After reviewing the medical histories of the nurses on the unit, the nurse manager determines which nurse can safely use latex products? 1. A nurse with a history of allergies to pollen and grass 2. A nurse with a history of allergies to bananas and kiwi 3. A nurse with a history of multiple surgeries 4. A nurse with a history of GI upset
A nurse with a history of GI upset
An RN reassesses the clients for the day shift. The nursing team includes one RN, two LPNs, and four nursing assistants. The nurse determines that assignments are appropriate if which of the following patients is assigned to a nursing assistant? 1. A patient diagnosed with Crohn's disease requiring a sterile dressing change 2. A patient diagnosed with chronic renal failure requiring intake and output 3. A patient diagnosed with full thickness burns requiring IV morphine prior to a dressing change 4. A patient diagnosed with cancer of the lung complaining of a headache
A patient diagnosed with chronic renal failure requiring intake and output
The nurse manager discusses substance abuse among nurses. The nurse knows which activity alerts the nurse manager to a potential problem with substance abuse among the staff? 1. A staff member changes hair color frequently 2. A staff member appears quiet in group meetings 3. A staff member frequently arrives early for work 4. A staff member does not allow another nurse to sign when narcotics are wasted
A staff member does not allow another nurse to sign when narcotics are wasted
The nursing teams consists of two RNs, one LPN, and two nursing assistive personnel. The nurse considers the assignment appropriate if the LPN is required to complete which task? 1. Obtain vital signs for the client immediately after ECT 2. Assist the client with bathing and feeding 3. Administer a tube feeding for the client with dysphagia 4. Discharge the client diagnosed with multiple sclerosis
Administer a tube feeding for the client with dysphagia
Which client assignment on a maternity unit does the nursing assistive personnel question? 1. Ambulate a client 24 hours after the birth of the child 2. Administer acetaminophen for pain to a client who has an episiotomy 3. Assist a client with morning care 4. Give the client pads for vaginal bleeding
Administer acetaminophen for pain to a client who has an epiosotomy
The nursing team consists of two RNs, two LPNs, and two nursing assistive personnel. Which client assigned to the LPN does the LPN question? 1. An infant requiring a bath prior to discharge 2. An infant with a palpable olive-shaped mass in the epigastrium and frequent vomiting 3. An infant requiring eye drops instilled 4. An infant requiring a rectal temperature taken every 6 hours
An infant with a palpable olive-shaped mass in the epigastrium and frequent vomiting
The nurse educator reviews conflict management strategies with new nurse managers. Which strategy does the educator highlight as most likely to be successful when there is conflict among staff? 1. Remind staff in conflict of their professionalism and common goal of quality of care 2. Refer conflicting parties to policy and procedure manuals and job descriptions 3. Explore family-of-origin conflict management experiences of the conflicting staff 4. Ask for suggestions for resolution from those involved in the conflict
Ask for suggestions for resolution from those involved in the conflict
The nursing team consists of two RNs, two LPNs, and two nursing assistive personnel. Which client does the nurse assign to a nursing assistive personnel? 1. Assist an elderly client with lunch 2. Administer famotidine to a client at 0800 3. Change a dressing for a postop client 4. Instruct a client about signs and symptom of lithium toxicity
Assist an elderly client with lunch
The new charge is hired to manage the pediatric unit. The charge nurse states in a meeting, "I run my unit with a lot of control and make all the decisions." The staff recognizes the new charge nurse is practicing which leadership style? 1. Autocratic 2. Laissez-faire 3. Democratic 4. Situational
Autocratic
The RN received an assignment for the night shift. Which task is appropriate for the nurse to delegate to a nursing assistive personnel with 20 years of experience? 1. Assess the breathing pattern of an asthmatic client 2. Monitor a client who is expectorating rust-colored sputum 3. Administer codeine to a postop client 4. Bathe a client prior to the scheduled 0600 surgery
Bathe a client prior to the scheduled 0600 surgery
The nurse notices a patient diagnosed with major depression crying in the day room. The nurse puts her hand over the patient's shoulder and states, "Let's talk about it." Which of the following ethical principles describes the nurse's action? 1. Autonomy 2. Veracity 3. Nonmaleficence 4. Beneficence
Beneficence
The nurse educator wants to enhance the creative and critical thinking skills of the nurses on the medical surgical unit. Which activity is best for the nurse educator to incorporate into an inservice in order to move toward this goal? 1. Review of steps of critical pathways 2. Demonstrates and returns demonstrations 3. Brainstorming experiences 4. True-false self-graded quizzes
Brainstorming experiences
A news reporter wants to take a picture of a movie start on the medical/surgical unit. Which action by the nurse is MOST appropriate? 1. Take the picture for the news reporter 2. Call the nurse manager 3. Contact the police 4. Report the incident to the client's healthcare provider
Call the nurse manager
The nurse manager wants to implement a three-day workweek on the nursing schedule. The nurse manager states, "Anyone who doesn't go along with the change will not receive vacation time this year." The staff identifies that the nurse manager is demonstrating which type of power? 1. Coercive power 2. Reward power 3. Expert power 4. Referent power
Coercive power
The nurse receives a call from the emergency department management team that a bomb exploded on a train and that 30 victims will be transported to the hospital in 10 minutes. Which of the following actions should the nurse take FIRST? 1. Inform the emergency management team that 10 patients will be accepted to the unit 2. No action is required 3. Contact the nursing supervisor 4. Tell the nurses on the shift that they will all have to work overtime
Contact the nursing supervisor
An RN discusses delegation with a new nurse. Which of the following statements by the new nurse indicates an understanding of the meaning of delegation? 1. Delegation means that the nurse is able to explain the nursing actions and results 2. Delegation occurs when an RN assigns a specific function of aspect of patient care to an LPN or UAP 3. Delegation occurs when the RN assigns a task that the RN does not have time to complete to another staff member 4. Delegation means being obligated to accomplish the work
Delegation occurs when an RN assigns a specific function or aspect of patient care to an LPN or UAP
qThe nurse reviews 10 charts on the medical unit. The nurse identifies which of the following actions is appropriate? 1. Failure to obtain informed consent 2. Failure to document in the patient's record 3. Failure to document changes in the patient's condition 4. Failure to document that an incident report was completed
Failure to document than an incident report was completed
The student nurse discusses causes of malpractice suits with the instructor. The instructor intervenes if the student includes which occurrence as an example of malpractice? 1. Failure to warn a potential employer of an RN's incompetence 2. Failure to staff a unit adequately 3. Failure to ensure that nurses are practicing in a competent manner 4. Failure to document within 30 minutes after a change in client condition
Failure to document within 30 minutes after a change in client condition
The nurse informs the nurse manager that she will be taking four weeks off because she is adopting two children. The nurse manager identifies which of the following acts allows the nurse to take time off? 1. Age Discrimination Act 2. Americans with Disabilities Act 3. Family and Medical Leave Act 4. Adoptions Leave Act
Family and Medical Leave Act
The nurse inserts an IV into a client diagnosed with AIDS. The client moves and the used needle sticks into the nurse's forearm. Which action BEST describes OSHA's requirements for what the employer must provide in this situation? 1. Free tetanus B vaccine 2. Immediate medical evaluation and treatment 3. Protective gowns and gloves 4. Employee training every four years
Immediate medical evaluation and treatment
A nurse approaches the nurse manager to ask for a raise. After some discussion about why the nurse feels a raise is warranted, the nurse manager suggests they discuss the raise further over dinner. The nurse refuses, and the nurse manager replies, "No dinner, no raise." Which action does the nurse take FIRST? 1. Immediately document the incident 2. Immediately report the incident to the supervisor 3. Immediately inform the nurse manager that the nurse does not want to go out to dinner 4. Immediately contact the nurse's family
Immediately inform the nurse manager that the nurse does not want to go out to dinner
The RN employed in a medical center in a large metropolitan area was asked to resign after consistently failing to report changes in client status to the healthcare provider. The RN subsequently applied for a staff nurse position in another hospital. Which action is BEST for the nurse manager to take when the new employer asks for a reference? 1. Consult an attorney 2. Inform the potential employer that the nurse resigned 3. Inform the new employer about occurrences 4. Ignore the request for a reference
Inform the new employer about occurrences
The nurse prepares a client for discharge from the neurological unit. The client must sleep with the head of the bed elevated 30 degrees, and the client cannot afford to buy a hospital bed that can be adjusted with levers or electronic devices. The nurse learns the client's insurance company will also not pay for the bed. What is the BEST action for the nurse to take? 1. Encourage the client to sleep on the couch with head resting on an armrest 2. Tell the client to have blocks placed under the foot of the bed 3. Instruct the client to collect or buy several pillows 4. Advise the client to awaken every 3 hours and stretch
Instruct the client to collect or buy several pillows
The nurse enters the room of a client admitted for evaluation of a convulsive disorder. The family members present report the client just had a seizure. After determining vital signs are normal, there are no injuries, and placing the client in side-lying position, which action will the nurse take NEXT? 1. Interview the family about what they observed and accurately document their response using their own words 2. Explore the feelings of the family regarding witnessing this seizure activity now and in the past 3. Document that the family witnessed a seizure but the nurse did not, and record the vital signs of the client 4. Instruct the family to call the nurse next time, complete an incident report, and notify the healthcare provider
Interview the family about what they observed and accurately document their response using their own words
The nurse describes the new nursing vice president's style of leadership. The nurse states, "The vice president lets us do what we want." The nurse is describing which leadership style? 1. Autocratic 2. Laissez-faire 3. Democratic 4. Situational
Laissez-faire
The nurse manager plans to conduct a performance appraisal. The nurse manager knows which action is MOST important during the interview phase? 1. Discuss mutual social interests with the staff member initially to put the staff member at ease 2. Emphasize areas of needed improvement and specific actions to take to address these 3. Maintain the focus on job position requirements, standards of care, and actual employee behaviors 4. Highlight which personality traits and attitudes of the employee are helpful and which are not
Maintain the focus on job position requirements, standards of care, and actual employee behaviors
Which of the following change strategies is most likely to be used by nurse managers who consider attitudes, values, and interpersonal relationships to be very important? 1. Normative-Reeducative Strategies 2. Empirical-Rational Strategies 3. Power-Coercive Strategies 4. Historical-Futuristic Strategies
Normative-Reeducative Strategies
Which document does the nurse know the force of law backs up? 1. Standards of nursing care 2. Code of ethics 3. Nurse practice acts 4. Nursing organization bylaws
Nurse practice acts
A day shift nurse gives change of shift report to the next nurse. The nurse knows which information is inappropriate for the nurse to include in the change of shift report? 1. Clients' names and room numbers 2. Clients' responses to tests 3. Client adverse incident 4. Nurses' opinions about clients
Nurses' opinions about clients
The nurse manager researches models of care delivery and decides to further explore primary nursing. The nurse manager identifies which model BEST describes primary nursing? 1. One RN is responsible for the client's total care throughout the client's hospitalization 2. The staff members perform specific tasks for a large group of clients 3. RN leader is responsible for coordinating a group of licensed and unlicensed personnel to provide client care 4. A team of staff members is assigned to a specific area of the nursing unit and cares for clients in that area
One RN is responsible for the client's total care throughout the client's hospitalization
The medical nurse reviews charting principles with newly assigned LPNs. Which of the following should the nurse indicate is charting that reflects subjective data? 1. T: 99.6, P: 90 bpm, R: 18, BP: 128/88 2. Patient states, "I have had pains in my stomach for three days now." 3. Bowel sounds heard in all four quadrants. 4. Patient ambulating with propulsive, unsteady gait.
Patient states, "I have had pains in my stomach for three days now."
The RN has assessed clients on the psychiatric unit. Which activity is appropriate for the nurse to delegate to a nursing assistive personnel on a psychiatric unit? 1. Perform 30-minute check on each client 2. Obtain lithium level on a client who may be toxic 3. Lead a group on anger management with eight clients 4. Administer fluoxetine to a client as ordered
Perform 30-minute check on each patient
The nursing team consists of two RNs, two LPNs, and two nursing assistive personnel. The nurse considers the assignment appropriate if an LPN is required to complete which task? 1. Perform a sterile dressing change 2. Obtain vital signs 3. Stock supplies of syringes and dressings 4. Transfer a stable client to x-ray
Perform a sterile dressing change
The nurse understands that risk management, within the context of managed care, focuses on which principle? 1. Educate clients about managing risk factors that would predispose to certain health conditions 2. Teach employees how to take risks safely in their personal and professional lives 3. Propose risk-taking activities for the institution that will enhance its public image 4. Prevent and minimize institutional and treatment factors that could lead to legal liability
Prevent and minimize institutional and treatment factors that could lead to legal liability
The nurse in the emergency department informs a client, "The physician is very busy and will see you in thirty minutes." The client demands to see the Director of Nursing. Which of the actions by the nurse is MOST appropriate? 1. Report the situation to the nurse's immediate supervisor 2. Contact the physician's supervisor 3. Inform the client he is being unreasonable 4. Contact the Director of Nursing
Report the situation to the nurse's immediate supervisor
The Director of Nursing wants to implement all-day visitor's passes. The nurse expressed their dissatisfaction about this potential change. The Director states, "If you all agree with me, you will et a lunch pass at the hospital's expense." The nurse identifies the director is using which type of power? 1. Coercive 2. Reward 3. Personal 4. Referent
Reward
The nurse manager of the psychiatric day hospital is reviewing group theory as part of the orientation of new nursing staff who are to develop and lead groups. The manager should identify which of the following group process stages as the one in which members are most likely to engage in arguments and power struggles? 1. Forming 2. Storming 3. Norming 4. Performing
Storming
A nurse begins employment in a hospital using the SOAP system of documentation. The nurse understands that SOAP is an acronym for which information? 1. Strategic Operational Accountability Protocol 2. Status, Orders, Actions, Precautions 3. Secure, Orderly, Appropriate, Precise 4. Subjective, Objective, Assessment, Plan
Subjective, Objective, Assessment, Plan
An RN from the maternity floor is reassigned to the emergency department. Which assignment is MOST appropriate for the maternity nurse? 1. The client at 20 weeks gestation reporting a small amount of vaginal bleeding 2. The client being admitted for suicidal thoughts 3. The client reporting numbness and tingling on the right side 4. The client being admitted for chest pain
The client at 20 weeks gestation reporting a small amount of vaginal bleeding
The charge nurse supervises care of clients on the medical/surgical unit. The charge nurse determines care is appropriate if which task is delegated to the nursing assistive personnel? 1. The client diagnosed with an ulcer requires the morning dose of famotidine? 2. The client diagnosed with COPD needs vital signs taken 3. The client requires discharge instructions 4. The client requires a sterile dressing change
The client diagnosed with COPD needs vital signs taken
In an effort to heighten staff awareness about group process and their participation in it, the nurse manager plans an inservice focused on the roles people take in groups. Which of the following should be described as the function of the role coordinator? 1. The coordinator arranges the room and furniture, distributes handouts, operates audiovisual equipment, and goes for what is needed 2. The coordinator clarifies relationships between various ideas or suggestions, thus bringing them together 3. The coordinator relieves tension in conflictual situations between group members, thus facilitating peace 4. The coordinator observes the group process and gives evaluative interpretations of what is observed to the group
The coordinator clarifies relationships between various ideas or suggestions, thus bringing them together
The nursing team on the pediatric unit consists of one RN, one LPN, and two nursing assistive personnel. Which client does the nurse assign to the LPN? 1. The child admitted with vomiting, weight loss, and abdominal pain 2. The child admitted with decreased hemoglobin and hematocrit reporting fatigue 3. The child diagnosed with a UTI who requires discharge instructions 4. The infant requiring antibiotic ointment on the circumcision site
The infant requiring antibiotic ointment on the circumcision site
The nurse manager delegates a task to another staff member. Which of the following includes appropriate technique to use when delegating? 1. The nurse manager maintains eye contact 2. The nurse manager asks staff members to report "any problems." 3. The nurse manager states what, how, and when a task should be performed 4. The nurse manager does not require feedback from the nursing staff 5. The nurse manager states, "you should do..." when describing the task. 6. The nurse manager allows the staff to determine the time when the task will be completed
The nurse manager maintains eye contact & the nurse manager states what, how, and when a task should be performed
The nurse is dissatisfied about the standard of care on the oncology unit. The nurse discusses this other nurses and a local news station. Afterward, the nurse is asked to resign by the nurse manager. The nurse responds to the nurse manager, "You can't fire my because I am protected by the whistle-blower law." Which statement BEST describes why this nurse may be subject to being fired? 1. The nurse is working under a union contract 2. The nurse may not be covered by the whistle-blower law 3. The nurse follows the institution's internal procedures 4. The nurse sends a copy of the complaint to the Director of Nursing
The nurse may not be covered by the whistle-blower law
The client is admitted with a stroke. The nurse notes the client has difficulty swallowing and requires assistance with bathing, toileting, and feeding. The delegation is appropriate if the RN delegates the tasks of bathing and toileting to which staff member? 1. The nursing assistive personnel 2. The LPN 3. The RN 4. The float nurse
The nursing assistive personnel
The nurse observes a student nurse give a presentation about incident reports. The nurse should intervene if the nursing student states that which of the following situations requires an incident report? 1. The physician orders citalopram (Celexa). The nurse administers olanzapine (Zyprexa). 2. At 1000 the nurse notes that the patient's BP is 80/50 and pulse is 110 bpm. Physician notified at 1300. 3. The patient falls while ambulating to the bathroom 4. The physician orders digoxin (Lanoxin) to be administered at 0900. The nurse administers the medication at 0920.
The physician orders digoxin (Lanoxin) to be administered at 0900. The nurse administers the medication at 0920.
An outside change agent consultant informs the nurse manager that most of the staff on the medical unit can be classified as "early majority" in terms of their behavioral patterns in response to change. The manager understands this to have which meaning? 1. The staff will not be the first to accept a change, nor will they be the last 2. The staff will thrive on change and see it as an exciting adventure which can advance their careers 3. The staff will be open and receptive to new ideas and will be sought out by others 4. The staff will be openly negative about changes and adopt them only after most others have done so
The staff will not be the first to accept a change nor will they be the last
The parents of an adult child have just been informed that the client will die shortly. The parents do not want the nurse to discuss the situation with the client. The nurse states, "I will be truthful." The nurse's action is based on which ethical concept? 1. Beneficence 2. Autonomy 3. Veracity 4. Nonmaleficence
Veracity (Telling the truth; intentionally deceiving a client violates this principle)
The RN assigns the client diagnosed with a myocardial infarction (MI) to another RN. The client receives the wrong medication by the assigned RN. The assigning nurse knows that which statement is true? 1. When an RN assigns care to another RN, only accountability is transferred 2. When an RN assigns care to another RN, both accountability and responsibility are transferred 3. When an RN assigns care to another RN, only responsibility is transferred 4. The assigned RN does not have accountability or responsibility
When an RN assigns care to another RN, both accountability and responsibility are transferred