NCLEX Practice Questions — Set 31
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
A new graduate nurse is interviewing for a staff position in a health care delivery system that has agencies in five different states. Which of the following statements indicates that the new nurse understands the legalities of nursing practice, if hired by this company?
Show answer and rationale
Correct answer: B. "The nurse practice act in each state will provide the legal guidelines for professional nursing practice."
Nurse practice acts may differ from state to state. The state board of nursing for each state monitors the legal practice of nursing in each state. Although standards of care may be policy at each agency, they do not override the standards outlined in the nurse practice act for each agency’s state. Once an RN license has been obtained, reciprocity to practice in other states must be granted by each state board.
After reviewing incident reports for 1�month, a nurse working in the risk management department at a local health care facility determines which of the following violations of client care is most common?
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Correct answer: D. Negligence of care
Negligence is the most common violation of client care in health care facilities. Negligence is a deviation from the appropriate standard of care, usually due to carelessness. Physical abuse, substance abuse, and malpractice actions are all criminal acts and occur less frequently.
Which of the following laws require a nurse to report a peer who is keeping a portion of narcotics ordered for a client?
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Correct answer: A. Reporting laws
Reporting laws in each state require a professional to report incompetent practice, client abuse, and professional impairment. Malpractice laws, jurisdiction laws, and civil court laws may vary from state to state.
Which of the following should the nurse manager include in staff development classes related to ethical decision making?
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Correct answer: B. Ethical decision making is based on knowledge, facts, and a strong commitment to right and wrong
Making ethical decisions requires skill in analyzing knowledge, facts, rules of care, and a strong personal distinction between what is right and wrong in a specific client situation. Opinion is not the driving force in decision making. Ethical decision making in client care made by an interdisciplinary team is ultimately possible when ethics committees meet to discuss individual client cases. It is important to remember that every nurse practices as an individual professional and incorporates ethical decision making into everyday practice.
The nursing manager on the orthopedic unit evaluates a new staff nurse on the night shift as a born "leader," based on which of the following true leadership qualities?
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Correct answer: A. The new staff nurse has scheduled staff journal club discussions once a month to increase current knowledge about client care issues
Knowing the importance of keeping up-to-date on practice issues and having the confidence to implement a strategy to discuss client care issues as a new staff member both demonstrate leadership quality in this staff nurse.
The astute nurse manager who wishes to empower the nurses on the unit recognizes that strategies must be found to promote their leadership ability. Which of the following supports the nurse manager’s knowledge of leadership?
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Correct answer: C. Leadership qualities are demonstrated by those in formal and informal management positions
Leadership qualities and an ability to influence others to achieve goals can be exhibited by any employee in an organization. Individuals with good management skills may not demonstrate leadership ability.
The nurse leader who empowers the staff to participate in decision-making activities is exhibiting which of the following leadership styles?
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Correct answer: D. Democratic
Democratic leaders seek participation in decision-making activities by all levels of staff affected at the unit level. Laissez-faire leadership is a passive and permissive style of leadership that defers decision making. An autocratic leadership style involves decision making that is centralized, with the leader making decisions and using power to command and control others. Situational leadership confirms that there is not one best leadership style, but rather that effective leadership is matched to the group’s level of task-relevant readiness.
The nurse describes which of the following leadership models as an integral part of the democratic leadership style?
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Correct answer: B. Transformational
Transformational leadership theory includes explicitly seeking collaboration, consultation, and consensus building among team members. Transactional leadership model is aligned with transactional leadership. Transdepartmental and transprofessional are strategies, not leadership models, for gathering information across departments within an organization or within the profession as a whole.
The nurse manager introduces to the staff the new organizational policy and procedural changes for administering blood products. According to Lewin’s model for implementing change, which of the following steps of the change process is the nurse manager addressing?
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Correct answer: C. Unfreeze
The first step for implementing change, or unfreezing, is to assist others to understand the need for change and the steps necessary to implement the change. Communication and information sharing are essential in this step. Actual implementation of the change and accepting the change as the standard of care are activities that occur with moving and refreezing. Evaluating is necessary for overall quality management, but is not a part of the change process as described by Lewin’s change theory.
A staff nurse has been assigned to the Standards of Care Committee in which the standard of care for wound care and dressing changes is going to be refined. As an effective change agent, the staff nurse will need to exhibit which of the following characteristics?
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Correct answer: C. Quality interpersonal skills
Although respect from clients and families, expertise in clinical therapeutics, and high ethical decision making are admirable for the staff nurse, the change process related to procedure of wound care and dressing changes will need to be discussed hospital-wide, unit by unit, utilizing quality interpersonal skills. Teaching and information sharing are essential when a change affects so many people, and these require quality interpersonal skills.
The nurse manager and staff of a 25-bed surgical unit have decided to change the client care delivery model from primary nursing to team nursing. The nurse manager prepares which of the following statements for the administration that is most appropriate to support this change?
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Correct answer: D. "The staffing goal is to have four teams, with a total of three to four RNs, two to three LPNs, and two nursing assistants for each shift."
A staffing goal of having four teams with a total of three to four RNs, two to three LPNs, and two nursing assistants is the best staffing option for implementing care based on flexibility and acuity of client care for a 25-bed unit. Transition in staffing and operational issues will be necessary even if all staff members have previously worked using a team nursing model. Assuming that all nursing assistants are senior nursing students is not a legally sound staffing assignment. Assigning a registered nurse to be responsible for 24-hour client care is indicative of a primary nursing model.
Based on an understanding of the differentiated nursing practice model, nurses on the burn and trauma unit have decided to assign certain client care activities because
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Correct answer: B. Bachelor of science nurses (BSNs) and master of science nurses (MSNs) are expected to plan and implement education and researchbased staff development sessions.
Expectations to plan and implement education and research-based staff development sessions by bachelor of science nurses (BSNs) and master of science nurses (MSNs) are best, considering that the assignment of educational sessions is based on the education level of the nursing staff. Differentiated practice includes the assignment of duties based on education level, competence, and certification. Nurses who have client care rounds, staff nurses who work overtime, and unit staff members who are held accountable for violation of unit requirements all require nurses to do similar activities regardless of education, clinical expertise, and competence levels.
Based on an understanding of the nurse manager�role, the nurse manager was notified at�home of a staffing issue for the night shift because the
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Correct answer: D. nurse manager has 24-hour, 7-day-a-week accountability for nursing care.
The nurse manager has 24-hour, 7-day-a-week accountability for nursing care. Nursing staff members are participative decision makers because of their position in the organization. Staff members should have input into the overall decision-making process.
Which of the following roles is the charge nurse applying when assigning unlicensed assistive personnel (UAP) to tasks of custodial care, vital sign monitoring, and intake and output measurement for all the clients on the unit?
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Correct answer: C. Delegation
Delegation is the assignment of tasks to others who are competent and skilled to perform them. Accountability and responsibility are qualities that all caregivers must demonstrate, regardless of level of position. Although the unlicensed assistive personnel (UAP) may collect data to carry out a nursing task, a nurse at a higher education level would be responsible for the overall evaluation and reporting.
The nurse manager incorporates which of the following functional roles of the team members when planning to conduct a class on effective team building and group process?
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Correct answer: A. Every group needs a person in the role of creator, coordinator, and record keeper
Every group needs a person in the role of creator and coordinator as well as a record keeper. This description contains the functional roles of members of a team. A dominator is a person who wants to dominate. Some teams always rally around the leadership traits of a member of the group or team, but it takes all team members working together collaboratively to be an effective team. Some teams are motivated to get the job done in spite of the dysfunctional behavior of a few team members, but to be a more effective group all team members need to work together.
The communication process is essential to the leader or manager role and to the role of the manager of client care. It is essential for all managers, including the manager of client care, to be effective communicators. The nurse who effectively analyzes the communication process understands that messages are
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Correct answer: D. verbal and nonverbal.
The most effective communication process includes both verbal and nonverbal cues. The terms synchronous and asynchronous and coded and encoded describe communication concepts within computer technology. Native and foreign describe language as being one’s first, or native, language or a language learned later, that is, a foreign language.
The nurse should consider which of the following sources of power to be most effective within an organization?
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Correct answer: D. Legitimate
Legitimate power is the minimum source of power, derived by merely holding a position of authority. Expert, referent, and connection are all sources of power that are derived in ways other than by holding a position. Expert power is power derived from the knowledge and skills the nurse possesses. Referent power, also known as charismatic power, is power conferred by others, based on their respect and liking for an individual, group or organization. Connection power is the connection between nurses having power, such as networking between positions of authority.
The nurse manager called a meeting with one of the unit team leaders because clients have complained that they are not receiving their medication on time. The nurse manager should include which of the following good time management strategies during the meeting with the unit team leader?
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Correct answer: A. All team leaders must look at the overall work to be done and set appropriate priorities
All team leaders must look at the overall work to be done and set appropriate priorities. Time management can be accomplished by knowing the overall needs of the clients and then setting appropriate priorities. Team leaders who take the first half hour of every shift to set priorities are lacking time management skills; the tasks could be handled by efficient shift reporting. During a nursing shortage, time management skills are essential and should be realistic.
The charge nurse must transfer a client from a medical-surgical unit to a maternity unit in order to make a bed available. It would be most appropriate for the charge nurse to transfer which client?
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Correct answer: C. A 55-year-old client with tonic-clonic seizures
Obstetrical nurses would have the appropriate knowledge and skills to care for a client having seizures because they routinely care for pregnant women who have hypertension and experience eclampsia (seizures).
A student nurse asks the nurse, "Why did my advisor recommend an ethics class for me?" Which of the following is the best response by the nurse?
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Correct answer: D. "Ethics must be learned in order to obey the law."
Recognizing ethical dilemmas is the responsibility of all nurses, as well as physicians. Ethical behavior is a component of both law and religion, but knowledge of these areas does not render studying ethics unnecessary.
The nurse tells another nurse that which of the following best describes the purpose of the American Nurses Association Code for Nurses?
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Correct answer: D. To communicate the values of the profession
The ethical codes of professions, such as nursing, are developed to communicate the values of the profession and to guide ethical behavior among its members. The code cannot make nurses behave ethically, nor is its purpose to defend nursing to other professionals or in legal matters.
Which of the following is the best example of an ethical dilemma faced by the nurse?
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Correct answer: C. Deciding whether or not to tell a client about the client’s diagnosis
An ethical dilemma exists when the nurse must make a decision about what is right or wrong, but there are conflicting moral principles or rules with any action taken. While deciding on room assignments and breaks are decisions nurses make daily, these are not ethical dilemmas. Nurses should use good judgment and refuse being assigned to clients whose care is too complex for their training. Withholding information about a diagnosis potentially brings up conflicting issues of veracity, fidelity, and beneficence and is therefore an ethical dilemma.
A nurse is asked to keep the client’s cancer progression from family members until after a daughter’s wedding next week, so as not to distract from this important day. This will require the nurse to withhold information from the client’s spouse and daughter who accompanied the client to the clinic. Which of the following actions by the nurse best demonstrates the theory of utilitarianism?
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Correct answer: B. The nurse does as the client wishes and keeps the diagnosis from the family until after the wedding
Utilitarianism is a moral theory that holds an action is judged as good or bad in relation to the consequences. It attempts to maximize the greatest good for the greatest number, giving equal weight to all parties involved. The nurse must consider the feelings of the client, family members, and all others potentially affected by the sharing of the diagnosis. According to the theory of utilitarianism, the nurse must suspend the principle of veracity in order to fulfill the wishes of the client and sustain the happiness that is sure to come to the family members through the wedding celebration. Although obtaining support from one’s family does support coping, there is no indication that the client is not coping well at this time, and there will be time for coping after the wedding. The nurse must also consider the obligation to uphold the client’s confidentiality.
A nurse is asked to keep the client’s cancer progression from family members indefinitely. This will require the nurse to withhold information from the client’s spouse, who frequently accompanies the client to the clinic. Which of the following actions by the nurse best demonstrates the theory of Kantianism?
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Correct answer: D. The nurse considers multiple ethical principles and supports the client in telling the family, as should be done universally in such a situation
Kantianism, also called deontology, is based on the rationalist view that the rightness or wrongness of an act depends on the nature of the act. The theory of Kantianism uses the categorical imperative to test actions. This imperative states that a person should act asone would wish everyone to act (as if it were a universal law) in that situation. It also says that persons should be treated as ends rather than as means to an end. Pressuring the client treats the client as a means to the end, with which the nurse feels more comfortable and avoids conflict. Keeping the disease progression secret supports the client in treating the spouse as a means to an end by being dishonest. Neither truth telling nor confidentiality alone always applies under this theory, but what is important is a consideration of how one ought to behave if one’s actions were to become a universal law. Because sharing the cancer diagnosis with the family is known to support coping of the client and family, it would be generally accepted to support this behavior in most situations in order to uphold principles of beneficence, autonomy, and rule of veracity. Therefore, the nurse should not take the responsibility of telling, but should provide guidance, education, and support to the client’s behavior of telling.
After the physician explains the surgery to the client, the nurse provides the client with information about surgery, answers the client’s questions, and allows the client to agree or refuse to have surgery. Which of the following ethical principles is best described by the nurse’s actions?
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Correct answer: B. Autonomy
The principle of autonomy is upheld when sufficient information and guidance are provided by the nurse so that the client may freely give informed consent. Beneficence is doing good, whereas nonmaleficence is not doing harm. Truth telling is an ethical rule rather than a principle, and relates to the nurse’s obligation to be truthful out of respect for the client.
The nurse informs a young, healthy client that the scarce amount of flu vaccine will be given to older clients and those with immunosuppressed responses first. Which of the following ethical principles is best described by the nurse’s statement?
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Correct answer: A. Justice
Equitable distribution of resources is described by the principle of justice. Beneficence is doing good, and nonmaleficence is not doing harm. Autonomy is providing the freedom to act.
The nurse chooses to delay taking a break so that pain medication could be administered on time rather than making the client wait until the nurse’s break is complete. Which of the following ethical principles is best described by the nurse’s action?
Show answer and rationale
Correct answer: C. Beneficence
Beneficence is described as doing what one ought to do to promote good. Nonmaleficence is not causing intentional harm. Justice is the equitable distribution of resources. Autonomy is upholding a client’s right to make informed choices.
A mentally ill client with an order for a general diet requests a vegetarian meal. Which of the following actions by the nurse best demonstrates the nurse’s understanding of the principle of autonomy?
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Correct answer: B. If necessary, obtain an order from the physician for a vegetarian meal; otherwise, provide a vegetarian meal per the client’s request
Limited autonomy, such as what type of meal to eat, may be granted to those clients who are not deemed competent for other medical decisions. Neither the client’s family nor the power of attorney needs to be contacted to make a diet change, even if they make other types of medical decisions for the client.
The nurse returns to the client’s room in exactly four hours to administer the next dose of pain medication as promised. Which of the following ethical rules is best demonstrated by the nurse?
Show answer and rationale
Correct answer: D. Fidelity
Justice and nonmaleficence are ethical principles dealing with fair distribution of services and doing no harm. These are principles, not rules. Confidentiality is an ethical rule emphasizing the importance of respecting the client’s right to privacy of information. Fidelity is the rule demonstrated by this nurse by keeping the promise made and returning with the pain medication.
A nurse admitted an older adult with a history of alcohol abuse. The client asked for assurance that leather restraints would not be used under any circumstances during alcohol withdrawal after surgery. The nurse promised that no restraints would be used. After surgery, the client was very agitated, delirious, and combative. Although restraints were indicated to preserve the client’s safety, the nurse opposed using them because of the promise made. This action by the nurse was
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Correct answer: C. inappropriate because the promise was not safe.
The nurse should not have made a promise that would possibly compromise the client’s safety. The client could also receive some medication for the agitation, delirium, or combative behavior.
A staff member observes a nurse assigned to a postoperative nursing unit reading the chart of a friend’s grandmother who is a client on the unit. The nurse is not assigned to this client and does not have a responsibility for this client’s care. The client was just diagnosed with terminal cancer and the family does not know. The staff member evaluates the action by the nurse as
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Correct answer: B. inappropriate because the grandmother is not assigned to the nurse.
Nurses only have the right to health care information that involves the clients for whom they are responsible and to whom the nurses have a duty.
The nurse is concerned about the medical care a long-term care resident is receiving. The nurse asks an opinion about the medical care from a physician who is not responsible for the client. The nurse has
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Correct answer: C. violated the principle of confidentiality.
A resident of a long-term facility, as other clients, has the right to confidentiality about personal health care information. If the nurse has a concern, the matter should be discussed with the primary physician.
A nursing home resident is offered the opportunity to participate in research on a new drug therapy to treat pressure ulcers. The resident decides after signing the consent form not to participate in the research project. Based on an understanding of the legal issues related to nursing homes, which of the following is appropriate in this situation? The client
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Correct answer: A. can withdraw at any time from the study.
Even though living in a long-term care facility, the older adult is considered competent unless legally declared otherwise. A client can withdraw from a research study at any time.
The nurse is eating lunch in a nursing home cafeteria. Two nurse aides can be heard at the next table talking about a resident by name. Which of the following is the priority nursing action?
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Correct answer: D. Tell the nurse aides that they are breaching confidentiality
Residents of a nursing home, as all clients, have the right to confidentiality. The priority actionis to deal with this inappropriate behavior as soon as it occurs. The nurse has the responsibility to protect the resident’s privacy.
The nurse is working in an outpatient same-day surgery unit. An 86-year-old client signs the surgical consent form and asks the nurse, "What did I just sign? My wife always takes care of the paperwork." Which of the following is the priority nursing action?
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Correct answer: D. Assess what the client understands about the surgery
Assessment of the client’s understanding of the surgery is essential. If a client has signed a surgical consent form then questions what was signed, it is a priority to assess what the client understands. After assessing what the client understands, or if the client is incompetent, then it would be appropriate to notify the physician.
Which of the following is the appropriate nursing action when a nursing student assigned to the surgery suite for observation asks the nurse for permission to photocopy the surgical record from a client’s chart for an assignment the student must write?
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Correct answer: A. Allow the student to write down pertinent but no identifying information
When a nursing student wants to photocopy a client’s medical record, nonidentifying information may be written down. The client has the right to confidentiality and any information that could be linked to the client, such as names or addresses, cannot be shared.
The nurse working in a long-term care facility is orientating a new nurse to the facility. The nurse should tell the new nurse that which of the following is the priority reason that health care issues of older adults become an ethical dilemma?
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Correct answer: B. The legal rights of the client coexist with the health professional’s obligation to provide care for the client
Although health care options do not seem clearly right or wrong and decisions in a longterm care facility are made quickly, the priority reason health care issues in older adults become highly charged ethical dilemmas is that the client’s rights to care and for a dignified death are managed in the context of the health professional’s obligations to provide care.
A nurse is accused of which of the following when writing on an older adult’s transfer papers to a long-term care facility that "he is a dirty old man"?
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Correct answer: B. Defamation of character
Defamation of character is an oral or written communication to a third party that damages a person’s reputation, such as transferring a client from one facility to another and writing on the discharge papers that "he is a dirty old man."
The temporary nurse from a registry is working on the night shift in a long-term care facility. This nurse has had little experience working with the older adult. Which of the following is an appropriate assignment for the charge nurse to give the nurse from the registry?
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Correct answer: C. Six clients who are stable
A nurse who is not familiar with the agency or the clients should be assigned to the most stable clients. Assigning a nurse to a hospice client, to clients with fevers of unknown etiology, or to administering medication to clients all require knowledge of the particular clients.
The nurse is planning care for a group of older adult clients. Which of the following clients is a priority for the nurse to care for first?
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Correct answer: A. A 90-year-old client who has potassium of 6.7 mEq/L
Although a client with an infected knee replacement, a temperature of 38.3�C, or 101�F, and a client in need of a dressing change all need an assessment by the nurse, the client with a potassium level of 6.7 mEq/L is the most acute and at risk.
A nurse is teaching a class of new graduate nurses on negligence. Which of the following situations is a priority for the nurse to include in the class as an example of negligence?
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Correct answer: D. Not turning off the oxygen at the bedside when a client at home wants to smoke in bed
Negligence is the result of either omitting to do something that another reasonable person, guided by those ordinary considerations that ordinarily regulate human affairs, would do, or of doing something another reasonable or prudent person would not do. If there is imminent danger to a client, the nurse must take every measure to protect the client. It may be appropriate for the nurse such as in the case of a client with a sudden rash and the nurse withholds a prescribed antibiotic, which may contribute to the development of the rash. It is inappropriate to talk about a client outside of a long-term care facility because it violates the client’s right to privacy, but it is not negligence.
One of the unlicensed assistive personnel (UAPs) caring for an older adult with fragile skin report to the nurse a red, painful, and swollen IV site in the hand. Which of the following requests by the nurse does the UAP interpret as inappropriate and illegal?
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Correct answer: B. "Carefully take the IV out."
Unlicensed assistive personnel cannot legally perform a nursing function such as removing an IV. This would be interpreted as inappropriate and illegal.
After reviewing the records of four older clients in a long-term care facility, which of the following situations does the nurse recognize as violating the client’s right to privacy?
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Correct answer: C. Administering a medication to a client in the presence of other clients
The medications that a client receives are private. The medications should not be administered where someone else, such as another client, can see what the client is receiving. Placing the client’s name on the client’s bed, and placing a photograph in the client’s medical record or medication administration record are for the client’s safety and do not violate the right to privacy. Only authorized personnel have access to that information.
A 66-year-old client is admitted to a long-term care facility for rehabilitation following a total hip replacement. The client refuses to stay in the facility and tells the nurse, "I am going to walk home." Which of the following is the appropriate action by the nurse?
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Correct answer: A. Do not prohibit the client from leaving
A client who is in a long-term care facility for rehabilitation and who wants to go home is competent and able to make decisions, even if those decisions may endanger the client’ shealth. It would be inappropriate to prevent the client from leaving, because the client can make health care decisions unless incompetence has been declared. Restraining the client would be false imprisonment or battery.
The older adult client in a long-term care facility is soiled with feces. The client calls out, "Stop, don’t hurt me. Help!" while being bathed by the nurse. Because the nurse did not have the client or the client’s guardian’s expressed permission to bathe the client, the nurse is at risk for being accused of
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Correct answer: B. battery.
Because the client is protesting the bathing, the nurse could be accused of battery without the permission of the guardian. Battery is the unlawful touching of another person. Assault is an unjustifiable attempt or a threat to touch a person without consent that results in fear of immediate harm. The touching may not actually occur. Malpractice is a type of negligence in which any unreasonable act or professional misconduct results in injury to the client. Negligence is the failure to do something that a reasonable person, led by those ordinary considerations that ordinarily regulate human affairs, would do, or the doing of something another reasonable person would not do.
A 66-year-old client with developmental disabilities and schizophrenia living in a longterm care facility develops pneumonia and is seriously ill. There are no advance directives and no legal guardian. Which of the following is the appropriate nursing intervention as the client’s condition worsens?
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Correct answer: C. Provide all possible medical treatment including resuscitation
In the absence of advance directives by the client or a guardian, the nurse must provide all appropriate care.
A nurse observes a staff member telling an older adult client that if the client does not take prescribed oral medications, dessert will be withheld. The nurse reports the behavior of the staff member as
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Correct answer: D. assault.
Assault is a deliberate threat that the client believes could be carried through, or an unjustifiable attempt or threat to touch a person without consent that results in fear of immediate harm. Battery is unlawful touching of another person. Malpractice is a type of negligence in which any unreasonable act or professional misconduct results in injury to the client. Negligence is the omission of doing something that a reasonable person, led by those ordinary considerations that ordinarily regulate human affairs, would do or doing something another reasonable person would not do.
A new employee to a long-term care facility asks the nurse if pictures of the residents may be taken. The appropriate response is, "Pictures
Show answer and rationale
Correct answer: C. cannot be published without the resident’s or guardian’s permission."
The right to privacy includes the publishing of pictures or any other information about a client without the client’s or guardian’s permission. The nurse has the responsibility to advocate for and protect the client’s privacy. Pictures may be taken in a long-term care facility for the purpose of placing the photograph in the client’s medical record or on the medication administration record.
An older adult client receives a gift of boxed chocolate candy. The client has dementia and does not understand that the candy is the client’s and what it is. The nurse should
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Correct answer: C. tell the client the candy is the client’s and offer a piece.
When a client with dementia does not recognize that the candy gift belongs to the client, the nurse should take every opportunity to get the client to enjoy it. The candy is a gift and the personal property of the client. The nurse cannot take the candy. This could constitute larceny.
Based on an understanding of the legal liability in health care, a nurse who fails to monitor the bowel movement pattern of an older adult client, which leads to an impaction, has committed which of the following?
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Correct answer: C. Negligence
Negligence is the omission or commission of an act that departs from the acceptable and reasonable standards of practice. The nurse is expected to monitor the elimination patterns of clients. A nurse that fails to monitor a client’s bowel movement pattern and the client develops an impaction is accused of negligence.
A nurse allowed an older adult who is confused to hold onto her purse. Later, the client was receiving oxygen by nasal prongs and attempted to light a cigarette with a cigarette lighter from the purse. An explosion, fire, and injury subsequently resulted. The case goes to court and the nurse is charged with which of the following?
Show answer and rationale
Correct answer: A. Criminal negligence
Criminal negligence is the disregard of protecting the safety of another person. The nurse has the responsibility to protect the client. In this case, the nurse failed to protect the client with oxygen from lighting cigarettes with a lighter and sustaining injury.
An older adult client tells the nurse that the client has human immunodeficiency virus (HIV). The nurse should
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Correct answer: D. encourage the client to disclose this information to the client’s physician.
The nurse must protect the client’s right to privacy of health care information. Documenting a client’s HIV status in the client’s chart, telling the client’s physician, and informing the health care team who will come in contact with the client all violate the client’s right to privacy.
The nurse caring for an older adult tears the skin of the client while removing a piece of tape. The skin is attached to the upper arm and to the tape. The nurse cuts the attached part of the skin with a scissors in order to remove the tape. The nurse fails to understand that if harm comes to the client during the act of cutting the skin with the scissors, which of the following could the nurse be charged with?
Show answer and rationale
Correct answer: D. Malpractice
Cutting the skin of a client with a scissors could be considered a medical procedure and not within the scope of nursing practice. A charge of malpractice could result. Malpractice is a type of negligence in which any unreasonable act or professional misconduct results in injury to the client. Negligence is the omission or commission of an act that departs from the acceptable and reasonable standards of practice. Assault is an unjustifiable attempt or threat to touch a person without consent that results in fear of immediate harm. The touching may not actually occur.
The nurse caring for an older adult client soiled with feces fails to clean and bathe the client, leaving the client for another staff member to care for. Another nurse reports this nurse as guilty of
Show answer and rationale
Correct answer: C. negligence.
The nurse is failing to perform an expected action, keeping the client clean and safe from harm. This is negligence. Negligence is the omission or commission of an act that departs from the acceptable and reasonable standards of practice. Malpractice is a type of negligence in which any unreasonable act or professional misconduct results in injury to the client. Assault is an unjustifiable attempt or threat to touch a person without consent that results in fear of immediate harm. The touching may not actually occur. Nonmaleficence is a principle that requires the nurse to act in such a way as to prevent harm to a client.
Which of the following should the nurse include when teaching a class on restraint application in the older adult?
Show answer and rationale
Correct answer: D. A physician must evaluate a client within one hour after restraints are applied in an emergency situation
The least restrictive type of restraint should be used. If restraints are used in an emergency situation, a physician must evaluate the client within one hour after the restraint is applied. Restraints should be reassessed every hour and removed every two hours. Wrist and ankle restraints should not be applied with the client in a prone position because there is an increased risk for aspiration. The client should be placed in a supine position. A belt restraint should not be used just because the client is an older adult and without justification. This is considered false imprisonment.
The nurse is caring for an older adult client who is very combative and is constantly hitting the staff at a long-term care facility. The decision was made that extremity restraints are temporarily necessary. Which of the following is most appropriate to include in this client’s plan of care?
Show answer and rationale
Correct answer: A. Place the client in a lateral position
A client who has an extremity restraint should be placed in the lateral position. Placing this client in a supine position would place the client at risk for aspiration. Two fingers should be inserted under a restraint to prevent it from being too tight. The restraint should never be applied to the nonmovable part of the bed, to avoid the restraint from becoming too tight when the bed is raised or lowered. The skin under a restraint must be assessed every hour and the restraint must be removed every 2 hours.
The nurse appropriately applies a mummy restraint to which of the following clients?
Show answer and rationale
Correct answer: A. A screaming child prior to an eye irrigation
A mummy restraint is most generally used with a small child during some kind of short-term examination or treatment. Older adult clients should never be restrained because they are confused or combative. An adolescent would never be restrained just because of a drug reaction.
The registered nurse is preparing to delegate nursing tasks. Which of the following should the nurse delegate to unlicensed assistive personnel?
Show answer and rationale
Correct answer: C. Perform a neurovascular assessment on an older adult client who has a jacket restraint
Performing specific assessments, such as a neurovascular or an oxygenation assessment, or checking for skin integrity should not be delegated to unlicensed assistive personnel. These tasks require the skills of a nurse. Unlicensed assistive personnel may perform range-of-motion exercises on a client who has a restraint.
The registered nurse is preparing the client assignments for the day in a long-term care facility. Which of the following client assignments would be appropriate for the registered nurse to delegate to unlicensed personnel?
Show answer and rationale
Correct answer: D. Application of a prescribed restraint
Although unlicensed assistive personnel should not perform any assessments on a client with a restraint, they have been trained to apply the restraint. Administration of medications through a nasogastric tube, assessment of a postoperative stoma, and irrigation of a Foley catheter should be performed by a nurse.
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these findings, the nurse should implement which action?
Show answer and rationale
Correct answer: A. Discontinue the IV
This question requires that you focus on the data in the question and determine that the client is experiencing an infiltration. Next, you need to consider the harmful effects of infiltration and determine the action to implement. Because infiltration can be damaging to the surrounding tissue, the ppropriate action is to discontinue the IV to prevent any further damage
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time (PT) of 35 seconds. On the basis of the prothrombin time, the nurse anticipates which prescription?
Show answer and rationale
Correct answer: D. Holding the next dose of warfarin
The normal PT is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time. Therefore the prescriptions noted in the remaining options are incorrect
The nurse prepares to care for a client on contact precautions who has a hospitalacquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse should assemble which necessary protective items before entering the client’s room?
Show answer and rationale
Correct answer: B. Gloves, mask, gown, and goggles
This question addresses the subcategory Safety and Infection Control in the Client Needs category Safe and Effective Care Environment. It addresses content related to protecting oneself from contracting an infection and requires that you consider the methods of possible transmission of infection, based on the client’s condition. Because splashes of infective material can occur during the wound irrigation or suctioning of the tracheostomy, option 3 is correct.
The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age?
Show answer and rationale
Correct answer: B. Large stacking blocks
This question addresses the Client Needs category Health Promotion and Maintenance and specifically relates to the principles of growth and development of a toddler. Toddlers like to master activities independently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play, which is more appropriate for a school-age child.
A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure?
Show answer and rationale
Correct answer: B. "The best thing about this is that I can use it anywhere, anytime."
This question addresses the Client Needs category Psychosocial Integrity and the content addresses coping mechanisms. Guided imagery involves the client’s creation of an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It can be done anytime and anywhere; some clients may use other relaxation techniques or play music with it
A client with Parkinson’s disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem?
Show answer and rationale
Correct answer: B. Consciously think about walking over imaginary lines on the floor.
This question addresses the subcategory Basic Care and Comfort in the Client Needs category Physiological Integrity, and addresses client mobility and promoting assistance in an activity of daily living to maintain safety. Clients with Parkinson’s disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe
A client with renal insufficiency has a magnesium level of 3.6 mg/dL. On the basis of this laboratory result, the nurse interprets which sign as significant?
Show answer and rationale
Correct answer: C. Drowsiness
This question addresses the subcategory Physiological Adaptation in the Client Needs category Physiological Integrity. It addresses an alteration in body systems. The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 3.6 mg/dL indicates hypermagnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms of neurological depression, such as drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia. Bradycardia and hypotension also occur.
A client is scheduled for angioplasty. The client says to the nurse, "I’m so afraid that it will hurt and will make me worse off than I am." Which response by the nurse is therapeutic?
Show answer and rationale
Correct answer: C. "Can you tell me what you understand about the procedure?"
This question addresses the subcategory Caring in the category Integrated Processes. The correct option is a therapeutic communication technique that explores the client’s feelings, determines the level of client understanding about the procedure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 does not address the client’s fears, provides false reassurance, and puts the client’s feelings on hold. Option 4 diminishes the client’s feelings by directing attention away from the client and to the health care provider’s importance.
Event: The nurse is caring for a client with terminal cancer. Event Query: The nurse should consider which factor when planning opioid pain relief?
Show answer and rationale
Correct answer: B. Around-the-clock dosing gives better pain relief than as-needed dosing
Test-Taking Strategy: Focus on the subject and the client’s diagnosis. Around-theclock dosing provides increased pain relief and decreases stressors associated with pain, such as anxiety and fear. Pain is what the client describes it as, and any indication of pain should be perceived as real for the client. Opioid analgesics may be addictive, but this is not a concern for a client with terminal cancer. Not all opioid analgesics cause tachycardia.
The nurse is caring for a client who just returned from the recovery room after undergoing abdominal surgery. The nurse should monitor for which early sign of hypovolemic shock?
Show answer and rationale
Correct answer: B. Increased pulse rate
Test-Taking Strategy: Note the strategic word early. Think about the pathophysiology that occurs in hypovolemic shock to direct you to the correct option. Sleepiness is expected in a client who has just returned from surgery. Although increased depth of respirations occurs in hypovolemic shock, it is not an early sign. Rather, it occurs as the shock progresses. Increased orientation to surroundings is expected and will occur as the effects of anesthesia resolve. Remember to look for strategic words.
The nurse provides medication instructions to a client about digoxin (Lanoxin). Which statement by the client indicates an understanding of its adverse effects?
Show answer and rationale
Correct answer: D. "If my pulse rate drops below 60 beats a minute, I should let my health care provider know."
Test-Taking Strategy: This question is an example of a positive event query question. Note the words indicates an understanding and focus on the subject, adverse effects. Digoxin is a cardiac glycoside and a concern is toxicity. Adverse effects that indicate toxicity include gastrointestinal disturbances, eurological abnormalities, bradycardia or other cardiac irregularities, and ocular disturbances. If any of these occur, the health care provider is notified. Remember, note positive event queries.
The nurse is caring for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume?
Show answer and rationale
Correct answer: D. The client with kidney disease
Focus on the subject, the client at risk for excess fluid volume. Think about the pathophysiology associated with each condition identified in the options. The only client who retains fluid is the client with kidney disease. The client taking diuretics, the client with an ileostomy, and the client undergoing gastrointestinal suctioning all lose fluid; these are comparable or alike options. Remember to eliminate comparable or alike options.
Quinapril hydrochloride (Accupril) is prescribed as adjunctive therapy in the treatment of heart failure. After administering the first dose, the nurse should monitor which item as the priority?
Show answer and rationale
Correct answer: A. Blood pressure
Focus on the name of the medication and note the strategic word priority. Recall that the medication names of most angiotensin-converting enzyme (ACE) inhibitors end with "-pril" and that these medications are used to treat hypertension. Excessive hypotension ("first-dose syncope") can occur in clients with heart failure or in clients who are severely salt-depleted or volume-depleted. Although weight, urine output, and lung sounds would be monitored, monitoring the blood pressure is the priority. Remember to use pharmacology guidelines to assist in answering questions about medications.
The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?
Show answer and rationale
Correct answer: B. Reflecting a cultural value
Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement ith the speaker, or understanding of the procedure.
When communicating with a client who speaks a different language, which best practice should the nurse implement?
Show answer and rationale
Correct answer: D. Arrange for an interpreter to translate.
Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and are ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation
The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to describe the concept of acculturation. The nurse educator should make which most appropriate response?
Show answer and rationale
Correct answer: C. "It is a process of learning a different culture to adapt to a new or changing environment."
Acculturation is a process of learning a different culture to adapt to a new or changing environment. Option 2 describes ethnic identity. Option 3 describes an ethnic group. Option 4 describes a subcultur
The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action?
Show answer and rationale
Correct answer: D. Continue with the instructions, verifying client understanding.
Most Chinese Americans maintain a formal distance with others, which is a form of respect. Many Chinese Americans are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around the client so that the nurse faces the client is in direct conflict with this cultural practice. The client may consider it a rude gesture if the nurse returns later to continue with the explanation. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading.
The nurse identifies low-risk therapies to a client and should include which therapy(s) in the discussion? Select all that apply.
Show answer and rationale
Correct answer: A. all the above
Low-risk therapies are therapies that have no adverse effects and, when implementing care, can be used by the nurse who has training and experience in their use. Low-risk therapies include meditation, elaxation techniques, imagery, music therapy, massage, touch, laughter and humor, and spiritual measures, such as prayer. The other options are not considered low-risk therapies
Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?
Show answer and rationale
Correct answer: C. Sweet and sour chicken with rice and vegetables, mixed fruit, juice
Orthodox Judaism believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered.
An Asian American client is experiencing a fever. The nurse recognizes that the client is likely to self-treat the disorder, using which method?
Show answer and rationale
Correct answer: B. Foods considered to be yin
In the Asian-American culture, health is believed to be a state of physical and spiritual harmony with nature and a balance between positive and negative energy forces (yin and yang). Yin foods are cold and yang foods are hot. Cold foods are eaten when one has a hot illness (fever), and hot foods are eaten when one has a cold illness. Options 1 and 2 are not health practices specifically associated with the Asian American culture or the yin and yang theory.
The role of the nurse regarding complementary and alternative medicine should include which action?
Show answer and rationale
Correct answer: B. Educating the client about therapies that he or she is using or is interested in using
Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse’s role. Options 1, 2, and 3 are inappropriate actions for the nurse to take because they provide advice to the client.
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that they would like to take an herbal substance to help lower their blood pressure. The nurse should take which action?
Show answer and rationale
Correct answer: D. Encourage the client to discuss the use of an herbal substance with the health care provider.
Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be encouraged to avoid herbal substances with similar pharmacological effects because the combination may lead to an excessive reaction or to unknown interaction effects. The nurse should advise the client to discuss the use of the herbal substance with the HCP. Therefore, options 1, 2, and 4 are inappropriate nursing actions
The nurse educator asks a student to list the five categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, would indicate an understanding of the five categories of CAM?
Show answer and rationale
Correct answer: A. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine
The five categories of complementary and alternative medicine (CAM) include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. The other options contain therapies within each category of CAM.
A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?
Show answer and rationale
Correct answer: A. Transport the victim to the operating room for surgery.
In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action.
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?
Show answer and rationale
Correct answer: C. Reassess the client.
After a client’s fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client’s fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client’s care. An incident report is a problem-solving document; however, its completion is not documented in the nurse’s notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first?
Show answer and rationale
Correct answer: C. Identify tasks that can be performed safely in the ICU.
Floating is an acceptable legal practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.
The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
Show answer and rationale
Correct answer: B. Call the nursing supervisor.
Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and so this is not the appropriate action. Option 4 is an inappropriate and unsafe action
Which identifies accurate nursing documentation notations? Select all that apply.
Show answer and rationale
Correct answer: D. all the above
Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seemed or appears is not acceptable because these words suggest that the nurse is stating an opinion
A nursing instructor delivers a lecture to nursing students regarding the issue of client’s rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?
Show answer and rationale
Correct answer: D. Observing care provided to the client without the client’s permission
Invasion of privacy occurs with unreasonable intrusion into an individual’s private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication onstitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment
An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?
Show answer and rationale
Correct answer: D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."
The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client’s family or friends without the client’s permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client
The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?
Show answer and rationale
Correct answer: B. Contact the nursing supervisor.
If the HCP writes a prescription that requires clarification, the nurse’s responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification
The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate nursing action?
Show answer and rationale
Correct answer: A. Call the nursing supervisor and report the incident.
Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.
The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?
Show answer and rationale
Correct answer: D. A client receiving nasal oxygen who had difficulty breathing during the previous shift
Airway is always the highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?
Show answer and rationale
Correct answer: D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number 3 priority
A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice?
Show answer and rationale
Correct answer: C. A registered nurse leads nursing personnel in providing care to a group of clients.
In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).
A nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?
Show answer and rationale
Correct answer: D. A client with a fever who is diaphoretic and restless
The nurse should plan to care for the client who has a fever and is diaphoretic and restless first because this client’s needs are the priority. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. Waiting for pain medication to take effect before providing care to the postoperative client is best.
The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client’s room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?
Show answer and rationale
Correct answer: A. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.
The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP.
A new unit nurse manager is holding her first staff meeting. The manager greets the staff and comments that she has been employed to bring about quality improvement. The manager provides a plan that she developed and a list of tasks and activities for which each staff member must volunteer to perform. In addition, she instructs staff members to report any problems directly to her. What type of leader and manager approach do the new manager’s characteristics suggest?
Show answer and rationale
Correct answer: C. Autocratic
The autocratic leader is focused, maintains strong control, makes decisions, and addresses all problems. The autocrat dominates the group and commands, rather than seeks suggestions or input. In this situation, the manager addresses a problem (quality improvement) with the staff, designs a plan without input, and wants all problems reported directly back to her. A situational leader will use a combination of styles, depending on the needs of the group and the tasks to be achieved. The situational leader would work with the group to validate that the information that the leader gained as a new employee was accurate and that a problem existed. Then, the leader would take the time to get to know the group and determine which approach to change (if needed) would work best according to the needs of the group and the nature and substance of the change that was required. A democratic leader is articipative and would likely meet with each staff person individually to determine the staff member’s perception of the problem. The democratic leader would also speak with the staff about any issues and ask the staff for input with developing a plan. A laissez-faire leader is passive and nondirective. The laissez-faire leader would state what the problem was and inform the staff that the staff needed to come up with a plan to "fix it."
The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and three unlicensed assistive personnel (UAP) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse?
Show answer and rationale
Correct answer: B. A client requiring abdominal wound irrigations and dressing changes every 3hours
When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by the unlicensed assistive personnel (UAP). The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present?
Show answer and rationale
Correct answer: D. An increase in blood pressure
A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client was at risk for developing the potassium deficit because of which situation?
Show answer and rationale
Correct answer: B. Requires nasogastric suction
The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison’s disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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