MANAGEMENT OF CARE NCLEX EXAM 2024-2025, Exams of Nursing

Download MANAGEMENT OF CARE NCLEX EXAM 2024-2025 and more Exams Nursing in PDF only on Docsity! 1 | P a g e MANAGEMENT OF CARE NCLEX EXAM 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST|GUARANTEED PASS |LATEST UPDATE 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 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 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 2 | P a g e Bathe a client prior to the scheduled 0600 surgery 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 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." 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 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 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 5 | P a g e 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 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 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 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 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 6 | P a g e 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 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 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 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 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 7 | P a g e Maintain the focus on job position requirements, standards of care, and actual employee behaviors 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 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 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 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 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 10 | P a g e 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 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 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. 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 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 11 | P a g e 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 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 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 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 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 12 | P a g e A 13-year-old female vomiting every day for the last three months because she wants to lose weight for the summer 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 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 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 15 | P a g e 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 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 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 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 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 16 | P a g e 2. Quality review 3. Performance appraisal 4. Risk review Peer review 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 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 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 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 delegates a task to another staff member. Which of the following includes appropriate technique to use when delegating? 17 | P a g e 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 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 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 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 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 20 | P a g e A nurse documents changes to the patient's condition 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 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 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 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 nursing team consists of two RNs, two LPNs, and two nursing assistive personnel. Which client assigned to the LPN does the LPN question? 21 | P a g e 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 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 new unit manager is holding her first staff meeting. the manager greets the staff and comments that she has been employed to bring about performance improvement. the manager provides a plan that she developed, as well as a list of tasks and activities for which each staff member must volunteer to perform. addition, she instructs staff members to report any problems directly to her. what type of leadership style does the new manager's characteristics suggest? 1. autocratic 2. situational 3. democratic 4. lassiez-faire 1. autocratic the physician wrote a medication order for a client. the nurse thought the dosage was incorrect. she questioned the physician who said it was all right. still questioning, she asked another nurse, who said it was all right. the nurse gave the medicine, and the client suffered from an overdose. who is liable? 1. the physician and the two nurses 2. the physician 3. the nurse who gave the medication 4. both the physician and the nurse who gave the medication 4. both the physician and the nurse who gave the medication proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication? 1. gastrointestinal bleeding 2. myocardial infarction 3. emesis 4. rib fracture 4. rib fracture 22 | P a g e an apartment fire spreads to seven apartment units. victims suffer burns, minor injuries, and broken bones from jumping from windows. which client should be transported first? 1. a woman who is 5 months pregnant with no apparent injuries 2. a middle aged man with no injuries who has rapid respirations and coughs 3. a 10 year old with a simple fracture of the humerus who is in severe pain 4. a 20 year old with 1st degree brush on her hands and forearms 2. a middle aged man with no injuries who had rapid respirations and coughs -- doesn't appear to have injuries, but symptomatic --> need further diagnostics to determine what is happening 30 people are injured in a train derailment. which client should be transported to the hospital first? 1. a 20 year old who is unresponsive and has a high injury to his spinal cord 2. an 80 year old who has a compound fracture of the arm 3. a 10 year old with a laceration of his leg 4. a 25 year old with a sucking chest wound 4. a 25 year old with a sucking chest wound stable vs unstable 1. appears stable 4. may need a chest tube, may need a lung, need an intervention a car accident involves four vehicles on a remote interstate. the nearest emergency department is 15 minutes away. which victim should be transported by helicopter to the nearest hospital? 1. a 10 year old with a simple fracture of the femur who is crying and cannot find his parents. 2. middle-aged woman with cold, clammy, skin and a heart rate of 120 bpm who is unconscious. 3. middle aged man with severe asthma and a heart rate of 145 bpm who is having difficulty breathing. 4. 70 year old man with a severe headache who is conscious 3. middle aged man with severe asthma and a heart rate of 145 bpm who is having difficulty breathing. -- focus on physical symptoms a 7 year old boy with a compound fracture is being admitted to a pediatric unit. which of the following actions is best for the nurse to take? 1. ask the nursing assistant to obtain the child's vital signs while the nurse obtains a history from the parents 2. ask the LPN ti assess the peripheral pulses of the child's left leg while the nurse completes the admission forms 3. ask the LPN to stay with the child while the nurse talks with his parents 4. ask the nursing assistant to obtain equipment for the child's care while the nurse talks with the child and his parents 4. ask the nursing assistant to obtain equipment for the child's care while the nurse talks with the child and his parents --- minimal amount of intervention needed 25 | P a g e The nurse is caring for patients in the outpatient clinic. Which of the following phone calls should the nurse return first? 1. A patient with hepatitis A who states, "My arms and legs are itching." 2. A patient with a cast on the right leg, states, "I have a funny feeling in my right leg." 3. A patient with osteomyelitis of the spine who states, "I am so nauseous that I can't eat." 4. A patient with rheumatoid arthritis who states, "I am having trouble sleeping." 2. A patient with a cast on the right leg, states, "I have a funny feeling in my right leg." •The nurse cares for patients on the medical/surgical unit. Which of the following patients should the nurse see first? •1. An 89-year-old female who is 2 days postoperative for repair of a hip fracture and has a temperature of 100.5 F (38 C). •2. A 69-year-old male admitted for treatment of lung cancer who has facial swelling and neck vein distention. •3. A 45-year-old male admitted for angina who has a blood pressure 150/84. •4. A 19-year-old female admitted for abdominal pain complaining of a headache. 2. A 69-year-old male admitted for treatment of lung cancer who has facial swelling and neck vein distention •You have just received change of shift report about your assigned patients. Who will you see first? •1. A 22-year-old patient who has questions about how to care for the drains placed in her breast reconstruction incision. •2. An anxious 44-year-old client who is scheduled to be discharged today after having a total vaginal hysterectomy. •3. A 69 year old patient who is complaining of level 5 pain (0-10 scale) after having a perineal prostatectomy 2 days ago. •4. An usually oriented 78-year-old patient who has new onset confusion after having a bilateral orchiectomy the previous day. 4. An usually oriented 78-year-old patient who has new onset confusion after having a bilateral orchiectomy the previous day. •After receiving change of shift report, which patient will you assess first? •1. A 20 year old with possible acute myelogenous leukemia who has just arrived on the medical unit. •2. A 38 year old with aplastic anemia who needs teaching about decreasing infection risk prior to discharge. •3. A 40 year old with lymphedema who requests help to put on compression stockings before getting out of bed. •4. A 60 year old with non-Hodgkin's lymphoma who is refusing the ordered chemotherapy regimen. 1. A 20 year old with possible acute myelogenous leukemia who has just arrived on the medical unit. •After receiving a change of shift report at 0700, which patient will you assess first? •1. A 23 year old with a migraine headache who is complaining of severe nausea associated with retching. •2. A 45 year old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching. 26 | P a g e •3. A 59 year old with Parkinson's disease who will need a swallowing assessment before breakfast. •4. A 63 year old with multiple sclerosis who has an oral temperature of 101.8 F and flank pain. 4. A 63 year old with multiple sclerosis who has an oral temperature of 101.8 F and flank pain. •The nurse, caring for clients in the oncology clinic, receives four messages. Which of the following patients should the nurse call first? •1. A patient diagnosed with leukemia receiving chemotherapy who complains of fatigue and loss of appetite. •2. A patient who had a mastectomy 2 weeks ago and complains of itching at the incision site. •3. A patient newly diagnosed with colon cancer who states that his stool specimen tested positive for blood. •4. A patient diagnosed with lung cancer who complains of urinary incontinence and difficulty ambulating. 4. A patient diagnosed with lung cancer who complains of urinary incontinence and difficulty ambulating. •Which of these patients in the neurologic ICU will be best to assign to a RN who has floated from the medical unit? •1. A 26-year-old patient with a basilar skull fracture who has clear drainage coming out of the nose. •2. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a rupture berry aneurysm. •3. A 46-year-old patient who admitted 48 hours ago with bacterial meningitis and has an antibiotic order. •4. A 65-year-old patient with an astrocytoma who has just returned to the unit after having a craniotomy. 3. A 46-year-old patient who admitted 48 hours ago with bacterial meningitis and has an antibiotic order. •As charge nurse you are making assignments for the day shift. Which patient would you assign to the nurse who has been pulled from the post-anesthesia care unit (PACU) for the day? •1. A 35-year-old patient with osteomyelitis who needs teaching prior to hyperbaric oxygen therapy. •2. A 62-year-old patient osteomalacia who is being discharged to a long term care facility. •3. A 68-year-old patient with osteoporosis and a new orthotic device who knowledge of use of this device must be assessed. •4. A 72-year-old patient with Paget's disease who has just returned from surgery for total knee replacement. 4. A 72-year-old patient with Paget's disease who has just returned from surgery for total knee replacement. •You are precepting a nurse who has recently graduated and passed the NCLEX exam. The new nurse has been on the unit for only 2 days. Which patient should you assign to the new nurse? •1. A 68-year-old diabetic who is experiencing signs of hyperglycemia including rapid, deep breathing and mental status changing. •2. A 58-year-old diabetic with peripheral neuropathy and cellulitis of the left ankle. 27 | P a g e •3. A 49 year old diabetic who has just returned from PACU after a below the knee amputation (BKA). •4. A 72-year-old diabetic with diabetic ketoacidosis (DKA) on an IV insulin drip. 2. A 58-year-old diabetic with peripheral neuropathy and cellulitis of the left ankle. •You are the nurse manager in the burn unit. Which patient is best assigned to an RN who has floated from the oncology unit? •1. A 23 year old who has just been admitted with burns over 30% of the body after a warehouse fire. •2. A 36 year old who requires discharge teaching about nutrition and wound care after having skin grafts. •3. A 45 year old with infected partial thickness back and chest burns who has a dressing change scheduled. •4. A 57 year old with full thickness burns on both arms who needs assistance in positioning hand splints. 3. A 45 year old with infected partial thickness back and chest burns who has a dressing change scheduled •You are acting as preceptor for a new graduate RN during her second week of orientation. For which client would you assign the nursing care to the new RN under your supervision? •1. A 38 year old client with severe difficulty of breathing due to asthma. •2. A 63 year old stable client with tracheostomy needing trachcare every shift. •3. A 56 year old client with lung cancer just returned from left lower lobectomy. •4. A 49 year old new admission client with new diagnosis of esophageal cancer. 2. A 63 year old stable client with tracheostomy needing trachcare every shift. •Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? •1. A 34 year old patient newly diagnosed with multiple sclerosis. •2. A 68 year old patient with chronic amyotrophic lateral sclerosis. •3. A 56 year old patient with Guillain Barre syndrome in respiratory distress. •4. A 25 year old patient admitted with C4 level spinal cord injury. 2. A 68 year old patient with chronic amyotrophic lateral sclerosis. •After change of shift, you are assigned to care for the following clients. Which client should you assess first? •1. A 68 year old client on ventilator who needs a sterile sputum specimen sent to the laboratory. •2. A 57 year old client with COPD and pulse oximetry reading from previous shift of 90% saturation. •3. A 72 year old client with pneumonia who needs to be started on intravenous antibiotics. •4. A 51 year old client with asthma complaining of SOB after using a bronchodilator inhaler. 4. A 51 year old client with asthma complaining of SOB after using a bronchodilator inhaler. •A newly graduated RN is in the third week of orientation to the medical surgical unit. Which client is best for you, as charge nurse, to assign to the new graduate? •1. A 34 year old who had just admitted to the unit with periorbital cellulitis. •2. A 40 year old who needs discharge instructions after having skin grafts to the right thigh. 30 | P a g e 5. A LPN is assigned to insert a urinary catheter. •As charge nurse, you must rearrange room assignments to admit a new patient. Which two patients are best suited to be roommates? •1. A 58-year-old patient with urothelial cancer on multi-agent chemotherapy. •2. A 63-year-old patient with kidney stones who underwent open uterolithotomy. •3. A 24 year old patient with acute pyelonephritis and severe flank pain. •4. A 76-year-old patient with urge incontinence and a urinary tract infection. 3. A 24 year old patient with acute pyelonephritis and severe flank pain. 4. A 76-year-old patient with urge incontinence and a urinary tract infection. •You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. •1. An ambulatory dazed 25-year-old male with a bandaged head wound. •2. An irritable infant with a fever, petechiae and nuchal rigidity. •3. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity. •4. A 50-year-old female with moderate abdominal pain and occasional vomiting. 2. An irritable infant with a fever, petechiae and nuchal rigidity. 1. An ambulatory dazed 25-year-old male with a bandaged head wound. 4. A 50-year-old female with moderate abdominal pain and occasional vomiting. 3. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity. •These patients present to the ED complaining of acute abdominal pain. Prioritize them in order of severity. •1. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating. •2. An 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days. •3. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week. •4. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure like pain in the abdomen and flank within the past hour. 4. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure like pain in the abdomen and flank within the past hour. 2. An 11-year-old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days. 3. A 40-year-old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, 31 | P a g e and worsening symptoms over the past week. 1. A 35-year-old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating. The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a. Vasopressors to increase blood pressure b. Corticosteroids to reduce inflammation c. IV fluids to increase vascular volume d. Antibiotics to treat the underlying condition c. IV fluids to increase vascular volume The healthcare provider is planning care for four patients. Which patient is most in need of interventions aimed at preventing anemia. The patient a. with renal failure on hemodialysis. b. who has been NPO for 3 days. c. who is vegetarian. d. with a Jackson-Pratt drain. a. with renal failure on hemodialysis. A nurse in the Neonatal ICU administers adult-strength digitalis (Digoxin) to a 3-pound infant. As a result, the neonate experiences permanent heart and brain damage. The nurse can be charged with a. Tort b. Assault c. Malpractice d. Negligence c. Malpractice Which statement is true regarding medical legality? a. Consent for medical treatment can be given by a minor with a sexually transmitted disease (STD). b. A nurse who becomes ill and leaves during a shift is not abandoning patients if the supervisor is notified. c. A second trimester abortion may be obtained without state involvement. d. Student nurses cannot be sued for malpractice while in a clinical class setting. a. Consent for medical treatment can be given by a minor with a sexually transmitted disease (STD). The healthcare provider on a pediatric unit has received her assignments for the day. Which of the following patients should the healthcare provider assess first? a. The 17-year-old with a left pleural effusion complaining of chest pain 9 on a 0-10 scale. 32 | P a g e b. The 6-year-old with bronchitis with an IV antibiotic infusing at 30 mL/hr. c. The 11-year-old with pneumonia waiting for discharge instructions. d. The 3-year-old with asthma who has an oxygen saturation of 94% on room air. a. The 17-year-old with a left pleural effusion complaining of chest pain 9 on a 0-10 scale. The nurse is planning care for a client with status-post CVA and limited mobility. The client is scheduled for occupational therapy at 10:00am and physical therapy at 2:00pm. What times are nursing care are most appropraite? a. AM care at 0900, PM care at 1600 b. AM care at 0800, PM care at 1500 c. AM care at 0800, PM care at 1600 d. AM care at 0900, PM care at 1500 c. AM care at 0800, PM care at 1600 When a patient's nasogastric tube stops draining, what is the nurse's first action? a. Clamp for 1 hour. b. Check tube placement. c. Retract 2 inches. d. Instill 50 mL of water. b. Check tube placement. A father brings his 6-month-old son and a 3-year-old daughter for their routine check-ups. What is the nurse's best strategy? a. Examine the 3-year-old first, so she can show her brother. b. Ask the father to step out with one child, while the other is examined. c. Let the 3-year-old play during the baby's examination. d. Examine the 6-month-old first, while his sister watches. c. Let the 3-year-old play during the baby's examination. When assigning tasks to unlicensed assistive personnel, the nurse can ask them to do all the following EXCEPT a. Provide patient and family education b. Measure intake and output c. Assist a patient who is choking d. Report signs of skin breakdown a. Provide patient and family education After a conference with the family, a patient's care provider writes a Do-Not-Resuscitate order. What does the nurse understand when planning care for the patient? a. Death will take place within the next 72 hours, so family should prepare. b. DNR orders from a pervious hospitalization will be valid and legal. c. The patient and family may no longer make medical decisions. d. Nursing care will continue with the treatment orders in place. 35 | P a g e c. Ask the patient if she has been using illicit drugs. d. Encourage the patient to increase fluid intake. a. Notify the physician. What is the final step in the ethical decision-making process? a. Make changes based on an evaluation of the original plan. b. Carry out the decision. c. Identify the issue. d. Consult an ethics expert or committee. a. Make changes based on an evaluation of the original plan. A widowed woman is being admitted for emergency cardiac surgery by the nurse. She is asking the nurse questions about who will make decisions for her if something goes wrong during her surgery. Which of these is the correct course of action for the nurse? a. The nurse should inform and educate this client about advance directives, help coordinate their creation, and ensure they are in the medical record. b. The nurse is not involved with advance directives. She should alert a social worker that the patient needs help establishing advance directives. c. The nurse should inform and educate this client that the nurse will act as a healthcare proxy for the patient, should the client be rendered incapable of making medical decisions for herself. d. The nurse should inform the physician and advocate for the delay of surgery until the patient seeks legal counsel. a. The nurse should inform and educate this client about advance directives, help coordinate their creation, and ensure they are in the medical record. A terminally ill male patient who is mentally competent declines palliative radiation for his inoperable brain tumor. The nurse knows that this patient is refusing treatment based on which of these legal standards? a. The Health Insurance Portability and Accountability Act b. The Uniform Anatomical Gift Act c. The Patient Self Determination Act d. The Patients' Bill of Rights c. The Patient Self Determination Act Which of these examples is most illustrative of a nurse acting as an advocate for the patient? a. giving a postoperative patient pain medication even though he or she has refused it b. telling the patient which treatment would be best based on your clinical opinion and past experience c. sharing a patient's status over the phone with a concerned neighbor who calls to ask how the patient is doing d. explaining a patient's test results in greater detail after they've been given by the treating practitioner d. explaining a patient's test results in greater detail after they've been given by the treating practitioner A nurse is assigned five patients on a medical surgery floor. There are two LPNs and one nursing assistant also working the shift. Which of the following interventions are appropriate to delegate to the 36 | P a g e supportive nursing staff? Select all that apply. a. auscultating breath sounds on a 70-year-old client with emphysema b. changing bed linens on a 44-year-old client while he is in radiology for an MRI c. assisting a 83-year-old client with history of unstable gait to the restroom d. administering IV Toradol (Ketorolac tromenthamine) to a 56-year-old recovering from a stroke c. taking vital signs on a 65-year-old client whose blood pressure was last 80/46 a. auscultating breath sounds on a 70-year-old client with emphysema, b. changing bed linens on a 44-year-old client while he is in radiology for an MRI Which of these scenarios correctly describes proper delegation by a nurse? a. delegating a bath of a quadriplegic patient to a nursing assistant b. delegating wound assessment on a postoperative patient complaining of increased pain to a nursing assistant c. delegating vitals on a patient who is experiencing chest pain to a nursing assistant d. delegating a nursing assistant to educate a patient on a new medication a. delegating a bath of a quadriplegic patient to a nursing assistant The nurse is planning to delegate tasks for her patients at the nursing home. The nurse knows that she does not need which of these to ensure successful supervision of the delegated tasks? a. the ability to problem-solve b. the ability to provide timely follow-up c. the ability to provide clear direction and communication d. the ability to provide criticism and negative feedback d. the ability to provide criticism and negative feedback A 75-year-old female recovering from a broken hip is being discharged from a healthcare facility. After completing her care plan after discharge, the nurse learns that her patient has a 78-year-old husband with dementia that she cares for at home. He has been staying with other family members during her convalescence. Which of these is the correct course of action for the nurse? a. Leave the discharge care plan as it is; assume that the family will continue taking care of her husband. b. Trust that the patient's rehabilitation has been sufficient and she can immediately resume all previous activities related to caring for her husband at home. c. Confront the patient and ask her why she didn't disclose the information about caring for her husband prior to completing her discharge care plan. d. Re-evaluate and revise her discharge care plan to ensure that the patient and her husband are both well taken care of at home. d. Re-evaluate and revise her discharge care plan to ensure that the patient and her husband are both well taken care of at home. A nurse is taking care of a previously healthy adult patient with a newly diagnosed serious medical condition. The patient is apprehensive and confused by all of the information, tests, test results, and the number of medical practitioners involved in the care plan. The nurse knows that it is her job to inform and educate this patient on the rights and responsibilities of those receiving healthcare as specified in the Patients' Bill of Rights. According to this document, which of the following is not included in this 37 | P a g e discussion? a. the right to choose any provider or plan for healthcare b. the responsibility to inform the healthcare staff of any previous conditions and medications c. the right to refuse any treatment d. the right to be informed about and participate in the decisions regarding medical treatment c. the right to refuse any treatment (this is part of the Patient Self-Determination Act) The nurse working in the ICU takes a phone call from an unknown person inquiring about the status of one of the patients under her care. Which of the following is the best course of action for the nurse? a. Tell the person that the information cannot be given over the phone. b. Take all of the caller's information and list it in the patient's chart prior to sharing the requested information. c. Tell the person the patient's condition and reassure them the best care is being given. d. Check the patient's chart to see if the person is listed to receive confidential information about the patient's medical condition and care. d. Check the patient's chart to see if the person is listed to receive confidential information about the patient's medical condition and care. In which of these situations is a nurse in violation of HIPAA guidelines? a. The nurse has a conversation about a patient's change in status with the nurse that's about to take over care in earshot of a nurse's aid who is not assigned to that patient. b. The nurse forgets to close out a patient's electronic medical record and leaves the information on the monitor where it can be read by other patients and visitors. c. The nurse jots a patient's name and vitals on a scrap piece of paper rather than directly into the medical record, but shreds it after the information has been recorded. d. The nurse has a conversation with a patient about the results of his labs and other diagnostic tests with the patient's wife present in the room. b. The nurse forgets to close out a patient's electronic medical record and leaves the information on the monitor where it can be read by other patients and visitors.