Delegation and Supervision: NCLEX-RN Exam Answers

NSG 100

Delegation and Supervision: NCLEX-RN Exam Answers

A nurse is working on the medical/surgical unit. The nurse knows that which of the following tasks should NOT be delegated to nursing assistive personnel?

Select one:

• Setting up a meal tray for a 75 year old client with Alzheimer's disease
• Transferring a 70 year old client awaiting discharge from the bed to a wheelchair.
• Assessing a newly postoperative client's pain level.
• Setting up a water basin for a 45 year old client who wishes to shave at the bedside.

A patient is extremely upset and mentions something about a work-related issue that the nurse cannot understand. Whichof the following is the nurse's best response?

Select one:

• "Your job must be very important to you."
• "Calm down so I can understand what you are saying."
• "I'm not quite sure I heard what you said about your work."
• "It's natural to worry about your job."

A patient is to have arthroscopic surgery of the knee to repair a torn tendon. The patient says, "I don't know if I'll make it through this surgery." Which response by the nurse will encourage further communication by the patient?"

Select one:

• "You are not going to die."
• "The type of surgery you are having is minor."
• "Everything will be all right."
• "Surgery often can be frightening."

A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices a staff member who is not involved in the client's care reading his medical record. The nurse knows she should FIRST do which of the following?

Select one:

• Inform the staff member that without legitimate need for the information, staff should not

be reading the medical record.

• Nothing. The staff member has a hospital ID badge and is authorized to read the medical

record.

• Tell the client his medical records have been read by an unauthorized individual.
• Page the physician and ask if it's acceptable for the staff member to access the medical

records.' A woman is admitted to the hospital with high risk pregnancy. A laparotomy is scheduled.Preoperatively, which of the following goals is MOST important for the nurse to include on the client plan of care?

Select one:

• Emotional support
• Respiratory therapy
• Fluid replacement
• Pain relief'

An elderly client is hospitalized with Alzheimer's disease. His daughter tells the nurse that caring for him is too hard, but that she feels guilty placing him in a nursing home. Which of the following statements by the nurse would be MOST appropriate?

Select one:

• "Don't feel guilty. The only solution is to place your father in a nursing home."
• "Would you like me to help you find a nursing home that is not too expensive?"
• "I think I would feel guilty too if I had to place my father in a nursing home."
• "It is hard to be caught between taking care of your needs and your father's needs."

Like first stop the person from reading, before deciding to go tell A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client?

Select one:

• Restating
• Pacing
• Reflecting
• Paraphrasing

A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply)

Select one or more:

• "Your daily routines will be different when you get home."
• "You will do great! You just have to get used to it."
• "Tell me about your support system you'll have after you leave the hospital."
• " Why are you worried about going home?"

A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply)

Select one or more:

• "Your daily routines will be different when you get home."
• "You will do great! You just have to get used to it."
• "Tell me about your support system you'll have after you leave the hospital."
• " Why are you worried about going home?"

Which of the following strategies should a nurse use to establish a helping relationship with a client?

Select one:

• Allow communication to occur spontaneously throughout the nurse-client relationship
• Make sure the communication is equally reciprocal between the nurse and the client.
• Encourage the client to communicate his thoughts and feelings.
• Give the nurse-client communication no time limits.

The nurse is admitting a client who is jaundiced due to pancreatic cancer. The nurse should give the HIGHEST priority to which of the following needs?

Select one:

• Nutrition
• Urinary Elimination
• Skin Integrity
• Self-Image

The nurse is caring for a client hospitalized for observation after a fall. The client states, "My friend fell last year, and no one thought anything was wrong. She died 2 days later!" Which of the following responses by the nurse is BEST?

Select one:

• "Don't up think I'm taking good care of you?"
• "This happens to quite a few people."

• "We are monitoring you, so you'll be okay."
• "You're concerned that it might happen to you?"'

The nurse is caring for a famous basketball player who may have sustained a career changing injury. When asked by co-workers about the status of the client, she responds that she is not able to discuss her client. Which of the following ethical principles BEST supports her statement?

Select one:

• Accountability
• Justice
• Beneficence
• Confidentiality

The nurse is caring for a terminal cancer client at home. The nurse knows that which of the following ethical principles BEST supports keeping the client and family care consistent with the nurse's professional code of ethics?

Select one:

• Virtues
• Fidelity
• Justice
• Beneficence

The nurse is conversing with a young adult client regarding an ordered blood transfusion. It is clear to the nurse that the client does not understand the risks involved with the procedure. Which of the following statements BEST describes the nurse's role regarding informed consent for this procedure?

Select one:

• The nurse has someone else witness the signature on the consent.
• The nurse tells the client not to worry because blood transfusions are very common.
• The nurse informs the ordering physician that the client does not understand the risks

and will need further explanation.

• The nurse describes alternative treatments.

The nurse is preparing a client for surgery. When obtaining informed consent, the nurse should INITIALLY do which of the following?

Select one:

• Assess whether the client's understanding of the procedure is sufficient to give consent.
• Witness the client's signature.
• Explain the risks, benefits, and alternatives of the procedure.
• Tell the client that obtaining the signature is routine for all surgeries.

The nurse is preparing to perform an admission assessment on a 28 year old man being admitted for Crohn's disease. The nurse knows that according to the Patient's Bill of Rights, this client is responsible for which of the following?

Select one:

• Providing accurate information about medication and past illness
• Providing information about personal relationships
• Providing proof of insurance
• Consenting to treatment

The nurse is present during an informed consent discussion between the client and the physician regarding recommended surgery. The physician discusses the risks, benefits and alternatives of the procedure with the client. The nurse knows that the client's decision whether or not to have the surgery is based on which of the following ethical principles?

Select one:

• Nonmaleficence
• Beneficence
• Autonomy
• Capacity

To better answer NCLEX style questions, the student should consider the correct order of

the nursing process and:

Select one:

• Evaluate and then plan
• Assess and then implement
• Document and then implement
• Implement and then assess.

What is the first step a student should take in actively developing a personal foundation for nursing practice

Select one:

• Identify a personal ethical foundation
• Identify ethical issues in the clinical setting.
• Examine personal values and beliefs.
• Read articles about ethical decision-making.

A nurse is using an interpreter to communication with a client. Which of the following actions should the nurse use when communicating with a client and his family? (Select all that apply.)

Select one or more:

• Send at text message to the client
• Ask the family one question at a time.
• Send an Instagram photo to help explain the situation.
• Do not interrupt the family and interpreter at they talk.
• Use lay terms if possible

Which of the following is an example of a critical ethical and legal patient oriented issue?

Select one:

• Individualized meal times
• Rationing of care
• Access to home care
• The size of patient rooms

Which of the following is the correct order for prioritizing needs according to Maslow's Hierarchy of Needs?

Select one:

• Creative activities, feelings of accomplishment, friends
• Psychological, basic, self-fulfillment needs
• Friends, security, safety
• Physical, safety, psychological needs

Which organization is responsible for ensuring the quality and integrity of baccalaureate, graduate, and residency programs in nursing through the process of accreditation?

Select one:

• ANA
• Sigma Theta Tau
• CCNE
• NLN

Which statement describes the following proverb: What you do speaks so loudly, I cannot hear what you say.