Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
This study guide provides a comprehensive overview of basic nursing practice concepts, focusing on nclex-pn remediation. It includes multiple-choice questions with rationales, covering topics such as the philosophy of alcoholics anonymous, documentation rules, conflict resolution, preoperative medication administration, consent for autopsy, delegation principles, practical nurse education, body mechanics, client introductions, postoperative positioning, grieving process, and client care. The guide aims to help students prepare for the nclex-pn exam by reinforcing key concepts and providing practice questions.
Typology: Exams
1 / 111
Rationale
Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.
o "I will record in the chart using black ink pen."
Rationale The LPN should document the details when they are observed, but the details should not be written based on opinions. Black ink pen should be used to record in the chart. The LPN should not include generalized empty phrases in the details. The LPN should never leave empty lines in the chart because another person may enter additional or incorrect information. The LPN should not wait until end of shift to record important changes that occurred several hours earlier,but record the events when they occur.
Rationale
Appropriate reasons for accommodating to resolve conflict include when the issues are trivial or not important, when the other person's ideas or solutions are better, or when harmonious relationships have to be preserved. Avoiding defensiveness is not an appropriate reason to accommodate when resolving conflict. Gathering more information is not an appropriate reason to accommodate when resolving conflicts, unless that additional information has shown that the nurse has made a mistake.
Rationale
Consent must be acquired when the client is fully oriented and in a clear mental state. Although important, having the client void can be implemented before surgery even if the client has received medication. Although important, checking the vital signs can be implemented before surgery even if the client has received medication. Although important, removing the client's dentures can be implemented before surgery even if the client has received medication.
Rationale
If a medical examiner's review is not necessary, the highest priority is given to the client. The client may provide the consent in writing before death. If the client or the surviving spouse is unable to give consent for the autopsy, a surviving child may be requested to give consent. The surviving parent may give consent for an autopsy if the client, the surviving spouse, and the surviving child are unable to do so. In case the client has not provided written consent before death, the nurse may obtain consent from the surviving spouse.
Rationale Questions such as, "Is the environment conducive to completing the task safely?" and, "Are the equipment and resources available to complete the task?" ensure the right circumstance for delegation. Right task is ensured with a question such as, "Is the task appropriate to the delegate, according to institutional policies and procedures?" Delegation is taking the right direction if the answer to a question such as, "Do the
delegator and delegatee understand a common work-related language?" is positive. Right supervision is evaluated with a question such as, "Is the delegator able to monitor and evaluate the client appropriately?"
o National Association for Practical Nurse Education and Service (NAPNES)
Rationale
Currently, the National Association for Practical Nurse Education and Service is regarded as the guiding force in the development of practical nursing education. Though not considered the guiding force in practical nursing education, the other organizations make contributions to nursing education as well. The National League for Nursing accredits nursing programs. The Young Women’s Christian Association established the first school of practical nursing in Brooklyn, New York. The National Federation of Licensed Practical Nurses is the official membership organization for licensed practical nurses and licensed vocational nurses.
Rationale
Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.
Rationale When the nurse introduces herself or himself to the client, this action decreases anxiety in the client. Explaining the procedure to the client will help to gain the
client’s cooperation. Identifying a client by his or her identification band will help to ensure the correct client is receiving the correct procedure. Assembling the thermometer, providing soft disposable tissues, having a lubricant pen and note pad, having disposable gloves, and having a plastic sleeve will promote an efficiently completed procedure.
Rationale
Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client, because it interferes with breathing.
Rationale
Detachment is a coping mechanism that the client needs, especially when faced with the inevitability of death; the nurse should accept this behavior. Ignoring the behavior does not convey a willingness to listen and denies the client's feelings. The client is in acceptance. It is unnecessary to point out the reality of the situation. It is counterproductive to encourage the client to become involved with the environment.
Rationale
Tuberculosis is an airborne contagious disease that is best contained in a negative airflow room. Negative airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.
Rationale
The nurse should document the physiologic status of the client in discharge and transfer forms. The nurse documents the client’s laboratory and radiology results in flow sheets. The nurse documents the functional status of the client in progress notes.
Judgment related to the nursing diagnosis of the client should be documented in the client care plan.
Rationale Chinese Americans are uncomfortable in face-to-face situations; they prefer to sit side by side or at right angles to carry on a conversation. For African Americans, the personal space comfort area tends to be close. Mexican Americans often use touch and value closeness and physical contact in familiar situations. African Americans, especially those belonging to the older generation, often find eye contact uncomfortable. Muslim American women do not usually shake hands with men; Native Americans, not Chinese Americans, extend a hand and lightly touch the hand of the person they are greeting instead of shaking hands. Native Americans are initially silent and reserved when meeting someone but demonstrate warmth once someone becomes familiar to them. When introducing themselves by name, Native Americans give honor to their ancestors by stating the clan and the location of their home area.
o Instruct the client to quit smoking
Rationale
Proper nursing interventions for an older client with hypertension include advising the client to limit salt intake, teaching stress management, and instructing the client to quit smoking. Skin care is an appropriate intervention for clients at risk of pressure ulcers. Information about immunization is provided to older adults at a risk for developing influenza. The nurse should advise a client with dementia to eat finger foods such as sandwiches because these foods are easy to eat.
Rationale
The preference for treatment should be always given to problems that have the greatest urgency such as life-threatening conditions. Secondary preference should be given to problems that are encountered first, problems that appear to be easiest to resolve, and problems that take the shortest amount of time to resolve.
Rationale The Health Insurance Portability and Accountability Act (HIPAA) protects the confidentiality of health information. The nurse is following the law by avoiding discussion of a client’s reports outside the health-care facility. The Patient Self- Determination Act (PSDA) emphasizes the right to accept or refuse treatment and requires institutions to maintain written policies and procedures regarding advance directives; this is the law the nurse is following by advocating for a client’s wish to donate organs after death. This law also calls for the health-care provider to seek permission to apply life support in an incapacitated client. A nurse who discusses a client’s condition with a primary health-care provider in another facility may be in breach of HIPAA if the client has not explicitly signed a release form for the nurse to do so.
Rationale Medicare is a health insurance program administered by the U.S. government as part of the Social Security Act. Based on the disorders alone, a client with permanent kidney failure is the most likely to receive Medicare. Dementia, depression, and type 2 diabetes mellitus are considered lower-priority disorders in terms of Medicare eligibility.
Rationale
The most fundamental ethical principle in the health care setting is respect for people. Justice is the concept of fairness. Truthfulness is telling the client the truth. Freedom of personal choice or autonomy is the right to be independent and make decisions freely. These are all important but not as fundamental.
o "The basis of this leadership style is the manager’s flexibility in adapting to the needs of the group or individual."
Rationale
In situational leadership theory, the manager has flexibility in adapting to the needs of the group or individual. Laissez-faire leadership is termed free-run style. This type of leadership style fosters professional growth of the manager and staff. It does not work well with highly motivated professional groups.
Rationale Dependent edema around the area of feet and ankles often indicates right sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds then release to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2+ indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.
When the delegatee has an ongoing relationship with the delegator, but a new task is assigned, the delegator should explain and demonstrate the procedure. When the delegatee has limited knowledge and ability to perform the task, the delegator should provide more guidance. When the delegatee has an established relationship with the delegator and the expertise, little guidance is needed from the delegator to perform the task. When the delegatee has the willingness and ability to perform a task, but the
relationship is new, it requires both individuals to create mutual expectations and the conditions for performance.
Pain is most effectively relieved when an analgesic is administered at the onset of pain, before it becomes intense; this prevents a pain cycle from occurring. Analgesics are less effective if administered when pain is at its peak. Before going to sleep, it may or may not be necessary; the medication should be taken when the client begins to feel uncomfortable within the parameters specified by the healthcare provider's prescription. Analgesics are less effective if administered when pain is at its peak.
o "I will make assignments for team members."
Rationale A licensed practical nurse (LPN) who serves as team leader has certain duties, which include administering medications, receiving reports on assigned clients, and delegating assignments to team members. Conducting routine staff evaluations and submitting staffing schedules for the unit are responsibilities of the nurse manager.
Rationale A nursing action that is appropriate during the secondary survey is assigning a nurse, or other team member, to support family members. Maintaining privacy, having suction available, and giving supplemental oxygen are all interventions during the
primary survey.
Rationale The client and significant family members should be included in dietary teaching; families provide support that promotes adherence. The client already has received information about why salty foods should not be eaten. Explaining the dietary restriction to the client's visitors could violate confidentiality. The client should be involved in his or her own care; the client ultimately will assume the responsibility. The dietitian is a resource person who can give specific, practical information about diet and food preparation once there is a basic understanding of the reasons for the diet.
Rationale A hospice volunteer is responsible for providing companionship to a client and caregiver. A volunteer coordinator recruits and trains volunteers. A bereavement coordinator is responsible for assessing and supporting the bereaved survivor. A primary spiritual leader is responsible for supporting the client and the caregiver in coping with fears.
Rationale
A core interdisciplinary hospice team includes the social worker, medical director, and nursing coordinator. A hospice pharmacist and a volunteer coordinator are members of a primary hospice team.
Rationale
The fetus of a heroin-addicted mother is at risk for serious complications such as
hypoxia and meconium aspiration. It is important to notify the healthcare provider of the client's heroin use, because this information will influence the care of the client and newborn. This information is used only in relation to the client's care. With the client's consent, it may be shared with other social service or health agencies that become involved with the client's long-term care. The nurse manager of the unit may be notified as it relates to the care of the client and her newborn. Client information is
confidential and only necessary staff should be privileged to such information. Hospital security would only be notified if actual illicit substances were discovered on hospital premises.
Budgeting is the responsibility of a nurse manager. The role of nurse leader is to motivate the nursing subordinates. Resolving conflicts is the responsibility of both the nurse leader and the nurse manager. Penalizing for poor performance is a behavior of transactional leadership.
Psychological or emotional abuse involves the infliction of anguish, emotional pain, or distress through verbal or nonverbal acts. Sexual abuse is nonconsensual sexual contact including with someone who is incapable of giving consent. Physical abuse involves the use of physical force that may cause bodily injury, physical pain, or impairment. Material abuse is defined as illegal or improper exploitation of an older adult’s funds, property, or other assets.
Rationale The nurse leader should determine the information that has to be shared with followers,but should not give all information at once. The nurse leader should give only limited information; giving too much at once can create disinterest in the listeners. The nurse leader can share information through mail as it is a primary communication method. The nurse leader should use face-to-face communication over text messages.
(UNP) before delegating a task. Which right of delegation is followed by the nurse? o Person Rationale
The knowledge and experience to perform the specific task safely by the delegatee is assessed by the qualification of the delegatee, which determines whether he or she is
the right person. The right task involves assessing whether the task is legally appropriate to delegate or whether it is appropriate under institutional policies. The right direction involves the delegator providing clear and concise directions to perform the task. The right supervision is determined by whether the delegator is able to monitor and evaluate the client appropriately.
Rationale Home care services are cost effective. Home health services are for all age groups. Social workers take an active role in home health care. Intravenous therapy is included in home care services.
Rationale According to the Institute of Medicine (IOM) competencies of the twenty-first century, nurses are required to incorporate quality improvement into their work. A nurse performs this task by identifying potential hazards, designing interventions to improve quality, and evaluating the success of the strategies. In the given situation, the nurse is evaluating the success of a strategy to minimize clients' risks of falls. Using informatics involves the use of information technology for the purposes of communication, management of knowledge, and reduction of errors. Using evidence- based practice involves participating in research activities and integrating results of research with client care. A nurse is required to work with interdisciplinary teams to provide better care to clients. This action is done by cooperating and collaborating with the client, caregivers, and other health care workers.
Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract or trust that results in injury to another person. Common cause means to unite one's interest with another's.
Rationale Statistics indicate that the most frequent cause of falls in hospitalized clients is getting up or attempting to get up to the bathroom unassisted. Although moving the bedside table closer to the bed is helpful in reducing falls because it moves the bedside table closer to the client's center of gravity, it is not the primary intervention to prevent falls. Sedatives contribute to the risk for falls by altering the client's sensorial abilities. Although talking to the spouse may calm the client and contribute to sleep, it does not reduce the incidence of falls.
Rationale SBARR stands for Situation, Background, Assessment, Recommendation, and Read- back. In read-back, the nurse may repeat the order back to the primary health care provider to confirm correct understanding. In situation, the nurse discusses an aspect of the client’s care with the primary health-care provider. In assessment, the nurse discusses the previous medication details of the client. In recommendation, the nurse explains her plan of care to the primary health-care provider.
Rationale A client suffering from side effects of antihistamines should be provided safety needs. Because the client is drowsy and dizzy, he or she may lose a sense of balance and fall. Therefore, the client should be protected from any physical harm. Self-esteem needs are addressed when dignity and recognition are taken into consideration. Self- actualization needs involve personal growth and maturity. Love and belonging needs
also would not be applicable here.
Rationale