Leadership Management NCLEX Questions

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NCLEX: Management of Care, Inter...

50 terms Olivia_Monarrez Preview NCLEX 34 terms ben The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands?

• Every 2 hours
• Every 3 hours
• Every 4 hours
• Every 30 minutes
• Every 30 minutes

The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked by the registered nurse every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first-priority intervention in the event of this occurrence is which action?

• Immobilize the affected extremity.
• Remove jewelry and constricting clothing from the

victim.

• Place the extremity in a position so that it is below the

level of the heart.

• Move the victim to a safe area away from the snake and

encourage the victim to rest.

• Move the victim to a safe area away from the snake and encourage the victim to

rest.In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible.

The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first?

• A 6-year-old child being treated for bacterial meningitis

and on the tenth day of antibiotic treatment

• A 6-week-old infant admitted to the hospital for

decreased level of consciousness; shaken baby syndrome is suspected

• A 2-year-old child with cerebral palsy being admitted

to the hospital for surgical placement of a gastrostomy feeding tube the next day

• A 16-year-old child with a ventriculoperitoneal shunt

that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head

• A 6-week-old infant admitted to the hospital for decreased level of

consciousness; shaken baby syndrome is suspected The infant or child who is the most unstable should be assessed first. A 6-week- old infant with an altered level of consciousness suspected to have resulted from shaken baby syndrome is the most unstable client because the infant could be developing increased intracranial pressure (ICP) and require interventions for the complications associated with increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction could become unstable, but because this child is older and ready for the CT scan, he or she is stable at this time.The nurse is assigned to care for 4 clients. Which client should the nurse assess first?

• A client who has a tympanic temperature of 99.8º F
• A client who has a regular radial pulse of 96 beats/min
• A client who has a supine resting blood pressure of

148/90 mm Hg 4. A client who has a peripheral (index finger) oxygen saturation percentage of 85%

• A client who has a peripheral (index finger) oxygen saturation percentage of

85% An oxygen saturation percentage of 85% is abnormal. If this is an accurate measurement, immediate intervention is needed to maintain the client's oxygenation status. A tympanic temperature of 99.8º F is mildly elevated and should be monitored, but it is a lower priority than respiratory status. A radial pulse of 96 beats/min is elevated as is the supine resting blood pressure of 148/90 mm Hg; both merit further assessment but are a lower priority than respiratory status.The nurse has received the client assignment for the day.Which client should the nurse care for first?

• The client receiving chemotherapy who is on day 3 of a

5-day regimen and has a question about nutrition

• The client receiving external radiation who has

complaints of dryness and itching skin at the treatment area

• The client who had a radical mastectomy 36 hours ago

and is complaining of tightness and pulling at the incision site

• The client admitted with the medical diagnosis of

neutropenia who is afebrile and is complaining of pain with urination

• The client admitted with the medical diagnosis of neutropenia who is afebrile

and is complaining of pain with urination The client admitted with neutropenia should be cared for first. The white blood cells serve as the primary defense against infections by destroying bacteria in the blood. The client is complaining of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly to contact the primary health care provider because clients with neutropenia are more susceptible to bacterial infections. The client who is tolerating the chemotherapy regimen and has a question is not a priority. It is not urgent that the nurse see the client with dryness and itching from radiation first. This is an expected effect from radiation therapy.The client who has a mastectomy is expected to have sensations of tightness and pulling.The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first?

• A victim experiencing excruciating pain
• A victim experiencing moderate anxiety
• A victim experiencing airway obstruction
• A victim experiencing altered level of consciousness
• A victim experiencing airway obstruction

Client needs related to maintaining a patent airway are always the priority.Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.

A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time?

• Ask the spouse about the client's wishes
• Get directions about care from the client's sister
• Prepare for emergency intubation
• Request that the sister provide a living will
• Get directions about care from the client's sister

A medial POA allows the client to designate a specific decision-making individual who can advocate for the client as needed and can be flexible in changing circumstances. The client's sister is designated as her POA. Though spouses are typically POA, option 1 is incorrect as he is not the designated POA. Option 3 would be appropriate only if there were no advance directives or family member present. Option 4 delays treatment.The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit?

• Did the study have institutional review board approval?
• Do the characteristics of the sample population match

those of the nurse's unit?

• What are the credentials of the study's researcher?
• What was the financial support provided for the study?
• Do the characteristics of the sample population match those of the nurse's unit?

When evaluating research for practice changes, the nurse must first determine if there is reasonable similarity between the nurse's unit population and the study population to expect equivocal results.The charge nurse in the emergency department assigns a client to a new nurse who has been off orientation for a week. Which client assignment is most appropriate?

• 3 year old with a temperature of 102.4 F (39.1 C) who

had a seizure at home 30 minutes ago and is very irritable

• 8 year old with a closed fracture of the clavicle

following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale

• 32 year old with asthma who has an upper respiratory

tract infection and a peak expiratory flow rate that is 45% of personal best

• 72 year old prescribe antibiotics 3 days ago to treat

acute sinusitis who reports shortness of breath and has a rash

• 8 year old with a closed fracture of the clavicle following a fall who is talkative

and rates pain as a "2" on the 0-10 FACES pain scale A fractured clavicle is not uncommon in children age <10 years and is usually treated conservatively. Additionally, the 8 year old has minimal pain and is therefore the most stable. The new nurse should be given the most stable patient.The nurse is caring for a hospitalized client with a diagnosis of thyrotoxicosis. Which of the following actions can be delegated to unlicensed assistive personnel? Select all that apply.

• Administer artificial tears if the client reports eye

dryness

• Assist the client to bathe and change the bed linens to

maintain client comfort

• Lower the room temperature and provide cool cloths

on request

• Reinforce to the client that fever is expected with

thyrotoxicosis

• Return a call to the client's family telling them the

client's condition is unchanged

• Assist the client to bathe and change the bed linens to maintain client comfort
• Lower the room temperature and provide cool cloths on request

UAP are authorized to perform activities of daily living, hygiene, linen changes, and positioning. Therefore, Option 2 and 3 are within a UAP's scope of practice.Option 1 involves medication administration, which is under the scope of a RN.Option 4 involves client teaching and also falls in the scope of practice of a RN.Although placing a phone call can be delegated, providing family with updates about the client's condition may require teaching and psychosocial support; therefore, Option 5 is not an appropriate task for UAP.

The nurse is caring for a client who is participating in a research study (randomized controlled trial) of a new medication. Which statement indicates that the client has an appropriate understanding of the study and reason for participation?

• "I changed my mind, but once in you're stuck."
• "I hope others will be helped through my involvement."
• "I know I will get new medication by being in this

study."

• "If I don't participate, my health care provider (HCP)

will be upset."

• "I hope others will be helped through my involvement."

Research with human subjects is reviewed by institutional research boards to ensure ethical principles are followed. The research participant cannot be deceived and must participate voluntarily knowing the risks and propose of the study. Clients in research studies often have altruistic motives. They know they may achieve no personal gain, but others could benefit from their participation.Four clients come to the emergency department (ED).Which client should the triage registered nurse (RN) assign as highest priority for definitive diagnosis and treatment?

• Client with chronic obstructive pulmonary disease

(COPD) with yellow expectoration and an oxygen saturation of 91%

• Healthy child with new-onset fiery-red rash on cheeks

and the "flu"

• Middle aged client with vaginal itching and white,

curdlike discharge

• Unconscious elderly client who smells of alcohol and

has fresh vomit on the face

• Unconscious elderly client who smells of alcohol and has fresh vomit on the

face Although this elderly client may be unconscious due to intoxication, vomit and decreased level of consciousness place this client at risk for airway obstruction.Treatment of this client is a priority, and measures must be taken to protect the airway (e.g., rescue position, head of bed elevation, intubation).The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action?

• Assess skin to determine severity of burns and wounds
• Assign client to a cot with other similarly triaged clients
• Assist the client to the designated showering area
• Prepare supplies to establish intravenous access
• Assist the client to the designated showering area

In the event of a disaster involving the release of hazardous substances, decontamination is vital to limit injury to the client and prevent exposure to other clients and staff. Disaster triage areas typically include a decontamination area. As long as the chemical remains on the skin, further injury may occur.The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit to the medical unit?

• Client newly admitted for an evolving ischemic stroke
• Client newly diagnosed with diabetes mellitus who

needs insulin administration teaching

• Client with exacerbation of chronic obstructive

pulmonary disease (COPD) with a new tracheostomy

• Client with sickle cell crisis who requires frequent

intravenous (IV) opioid medication for pain

• Client with sickle cell crisis who requires frequent intravenous (IV) opioid

medication for pain Sickle cell crisis is managed with IV hydration, frequent IV pain medication, and as needed blood transfusion. Many orthopedic clients require medication with opioids to control pain, IV fluids, and blood transfusion. The float nurse would not be familiar with the location of diabetic teaching materials, documentation procedure, or referral resources.