BoardVitals NCLEX Prep RN 126 preguntas

BoardVitals NCLEX Prep RN 126 preguntas

• While administering medications to a group of clients on a medical-surgical unit, a client

who is postoperative from an accidental above-the-knee amputation indicates to the nurse that he is ready to talk about his feelings. The nurse keeps her promise and returns to talk with the client as soon as she finishes administering medications. Which of the following ethical principles is the nurse demonstrating?

• Veracity
• Justice
• Nonmalecence
• Fidelity
• A nurse has assigned client care activities to an assistive personnel (AP). Which of the following

statements by the AP indicates a need for assistance with time management?

• "I will start working with the client in room 1, then work my way to room 10."
• "I will give this client his meal tray first because he is going to physical therapy early."
• "After breakfast, I will pack the belongings of clients who will be discharged this morning."
• "I will start by providing partial baths before breakfast."
• A nurse is updating the plan of care for a client who has a new diagnosis of hypertension and a

prescription for atenolol. Which of the following referrals should the nurse request from the provider as the priority referral?

• Dietitian
• Physical therapist
• Pharmacist
• Social worker
• A nurse on a pediatric unit is planning care for a group of clients. Which of the following clients

should the nurse plan to assess first?

• A school-age child who has diabetes mellitus and requires blood glucose monitoring
• An infant who has pertussis and is receiving oxygen via nasal cannula
• An adolescent who is 1 day postoperative following an appendectomy
• A toddler who is scheduled for an upper gastrointestinal X-ray series
• A nurse is caring for a client who has terminal lung cancer. The client's provider has recommended

hospice services for the client. Which of the following statements by the client should indicate to the nurse that the client understands hospice care?

• "I will have to be admitted to a long-term care facility in order to receive hospice care."
• "I should expect the hospice team to help me manage my difficulty breathing."
• "Hospice care services are available to anyone who is terminally ill, regardless of life expectancy."
• "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."
• A nurse in a provider's office is reviewing the laboratory findings for a client who is receiving

chemotherapy. The client has a platelet count of 60,000/mm3. Which of the following actions should the nurse take first?

• Provide the client with information about the treatment.
• Discuss these findings with the provider.
• Ask the client to return to the clinic for further laboratory tests.
• Obtain a referral to a specialized provider.
• A charge nurse is delegating tasks to nursing personnel on a ten-bed dementia care unit. Which of

the following assignments is an example of overdelegation?

• Assigning two assistive personnel (AP) to ambulate each client on the unit
• Assigning a newly licensed nurse to perform a wet-to-dry dressing change
• Assigning one AP to feed each client on the unit
• Assigning an experienced RN to perform a central line dressing change
• A nurse on a medical-surgical unit is delegating care for a group of clients. Which of the following

specimens should the nurse delegate an unlicensed assistive personnel (UAP) to collect?

• Wound drainage for culture
• Urine from an indwelling catheter
• Blood for an ABG test
• Random stool specimen
• A nurse accuses a newly licensed nurse of providing inadequate care for a client who underwent hip

arthroplasty. Which of the following responses by the newly licensed nurse demonstrates assertiveness?

• "I feel as though I met the standard of care. Would you tell me more about your concerns?"
• "You shouldn't make accusations. Your nursing care doesn't always set a good example."
• "I am sorry you are displeased. I always do my best to give good care to my clients."
• "Yes, you might be right. I haven't had the best role models since I started this position.

• A nurse is caring for a client who is participating in a research study for an experimental

chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should recognize that discontinuing this medication demonstrates which of the following ethical principles?

• Justice
• Autonomy
• Fidelity
• Nonmalecence
• A nurse on a quality assurance team is reviewing unit incident reports that were led within the last

six months. Which of the following incidents meets the criteria for a sentinel event?

• A client who was postoperative from surgery reported a valuable piece of jewelry was stolen from his

room.

• A client who was experiencing acute alcohol withdrawal hits a nurse, causing the nurse to fall to the

floor and break their wrist.

• A client who was having an anaphylactic reaction was administered epinephrine 0.75 mg

intramuscularly. The client experienced a cardiac event and died.

• An AP left a client on fall precautions unattended in the restroom, where the client fell and sustained a

scrape to the knee.

• A nurse manager is reviewing the admission history of four adult clients. The nurse is required to

report which of the following situations to an outside agency?

• An older adult client who is dependent on caregivers and was admitted for the treatment of burns on

the buttocks

• A young adult client who was admitted for asthma and has track marks that might indicate IV

substance use

• A young adult client who was admitted for acute glomerulonephritis following a viral infection
• An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
• A nurse is planning an in-service for nursing staff about managing care for clients who develop

disequilibrium syndrome. Which of the following interventions should the nurse include in the teaching?

• Administer an opioid medication.
• Monitor for the development of chest pain.
• Assess level of consciousness.
• Start an intravenous infusion of dextrose 50%

• A nurse is preparing to delegate tasks to an LPN and an assistive personnel (AP). Which of the

following tasks should the nurse assign to the LPN?

• Transporting a client who experienced a stroke 72 hr ago to the radiology department
• Providing a back rub to a client who has right-sided paralysis
• Removing and cleaning the cannula of a client who has a stable, exisiting tracheostomy
• Emptying the drainage from the ostomy bag of a client who has a new colostomy
• A nurse is planning an education program about heart health for adults in the community. Which

of the following principles should the nurse use when planning the program?

• The program should be teacher-directed.
• The content of the program should be problem-centered.
• The goals of the program should be set by the teacher.
• The program should be conducted in a formal atmosphere.
• A nurse is teaching a client about choosing a health care surrogate. Which of the following

statements by the client indicates an understanding of the teaching?

• "I can change who I designate as my health care surrogate as long as I have my provider's approval." B.

"If I become incapacitated, end-of-life choices will be made by my health care surrogate."

• "I have to choose a family member as my health care surrogate."
• "I can verbally indicate to my nurse who I want to assign as my health care surrogate."
• A nurse manager is planning strategies to overcome resistance among unit nurses for a proactive

policy change. Which of the following interventions should the nurse include?

• Emphasize that future revisions to the policy change are not an option.
• Openly discuss the reason for the change.
• Avoid redirecting the resistance of the nursing staff until opposition is resolved.
• Emphasize the reason for the change rather than the benefits of the change
• A nurse in a preoperative unit is caring for a client who is scheduled for surgery. The nurse is a

witness on the client's consent form. The nurse provides a signature on the consent form for which of the following purposes?

• Ensuring the client is of age to sign the form
• Confirming the client appears competent to provide consent
• Asserting the nurse has explained the risks and benefits of the procedure
• Recording that the client's partner agrees the procedure is necessary