NCLEX Management of Care

NCLEX Management of Care Leave the first rating Students also studied Terms in this set (69) Science MedicineNursing Save Q Review 1 101 terms eerainsPreview Hurst Review 1.2 124 terms Felicia_Townsend7 Preview NCLEX Review - Management of Ca...26 terms ish_jayme_penafiel Preview Physiol 106 term Mo Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult?

• Six year old who had surgery 5 days ago, receiving

clear liquid diet since surgery.

• Twelve year old admitted 5 days ago receiving total

parenteral nutrition (TPN).

• Two year old taking only clear liquids since admission

24 hours ago.

• Nine month old admitted 2 days ago for diarrhea and

now on ½ strength formula.

• Six year old who had surgery 5 days ago, receiving clear liquid diet since

surgery.(1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate.

• Incorrect: The child receiving total parenteral nutrition (TPN) has already had a

nutritional evaluation receiving supplementation for nutritional needs. After reviewing the nutritional evaluation, the TPN will be formulated accordingly.

• Incorrect: The two year old taking only clear liquids is acceptable until the child

is on liquids for more than 3 days, then would be at nutritional risk. After 3 days the nutritional status of the child should be evaluated due to the food restrictions of a clear liquid diet.

• Incorrect: The nine month old is being put back on formula at ½ strength. Once

this is tolerated, then the strength will be advanced; therefore, this client is not at risk.)

A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance?Select all that apply.

• Provides "just in time" posters outlining the importance

of pain assessment.

• Conducts brief in-services for each shift.
• Counsels nurses when pain level scale is not utilized.
• Ensures that a complete and clear performance

standard exists.

• Assesses nurses' reasons for not using pain level scale.
• Disciplines offenses through unpaid time off.
• Provides "just in time" posters outlining the importance of pain assessment.
• Conducts brief in-services for each shift.
• Counsels nurses when pain level scale is not utilized.
• Ensures that a complete and clear performance standard exists.
• Assesses nurses' reasons for not using pain level scale.

(1., 2., 3., 4. & 5. Correct: If nurses have been provided the knowledge and performed the skill before, but have not practiced the skill on a regular basis, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill.Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Counseling the nurses when pain level scale is not utilized may improve understanding and performance. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. Always assess why staff are doing or not doing what is needed for clients. There may be a lack of knowledge or there may be a sense of non-importance.

6. Incorrect: Quality improvement looks at improving processes and does not use

intimidation and punishment to improve quality care.) A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse?Select all that apply.

• Forty year old admitted with diagnosis of cholecystitis

to room 410 for surgical services.

• Appears to be having abdominal discomfort.
• Permit signed for laparoscopic cholecystectomy after

discussing procedure with surgeon.

• Pre op Diazepam 10.0 mg given po.
• Transferred to surgical suite per stretcher with side rails

up, in stable condition.

• Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical

services.

• Permit signed for laparoscopic cholecystectomy after discussing procedure

with surgeon.

• Transferred to surgical suite per stretcher with side rails up, in stable condition.

(1., 3, & 5. Correct: These are written correctly with complete, concise and objective information for each statement pertaining to the client.

• Incorrect: "Appears" is a subjective word. Remember to use objective words.

Pain should be assessed in an objective manner, such as by using a pain scale that is appropriate for the client's age and communication abilities. If the client were unable to respond to a pain scale assessment, the nurse would need to describe objectively the behavior of concern; for instance, the nurse could document "client moaning, guarding abdominal area with both hands, and knees pulled towards chest".

• Incorrect: Do not use trailing zeros after a decimal point to prevent incorrect

dosage. Likewise, always lead a decimal point with a zero (0.5).)

Which task would be appropriate for the charge nurse to assign to a LPN/VN?Select all that apply.

• Collect data on a new client admit.
• Administer morphine IVP to a two day post-op client.
• Bolus feeding a client who has a gastrostomy tube.
• Reinserting a nasogastric tube (NG) that a client

accidentally pulled out.

• Monitor patient control analgesic (PCA) pump pain

medication being delivered to a client.

• Collect data on a new client admit.
• Bolus feeding a client who has a gastrostomy tube.
• Reinserting a nasogastric tube (NG) that a client accidentally pulled out.
• Monitor patient control analgesic (PCA) pump pain medication being delivered

to a client.(1., 3., 4., & 5. Correct: All of these tasks are appropriate and within the scope of practice for the LPN/VN. The LPN/VN can collect data on a new admit, and the RN would verify and co-sign to complete the assessment. Bolus feeding by way of a gastrostomy tube and reinserting a nasogastric tube would be appropriate assignments for the LPN/VN also. A LPN/VN can monitor the PCA pain medication but cannot initiate or administer the medication.

• Incorrect: Administering morphine IVP is out of the scope of practice for the

LPN/VN since it is a complex, high risk IV push medication and has the potential to depress the client's respiratory rate.) Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)?Select all that apply.

• Bathe the client who is on telemetry.
• Apply cardiac leads and connect a client to a cardiac

monitor.

• Help position a client for a portable chest x-ray.
• Feed a client who is dysphagic.
• Collect a stool specimen.
• Bathe the client who is on telemetry.
• Apply cardiac leads and connect a client to a cardiac monitor.
• Help position a client for a portable chest x-ray.
• Feed a client who is dysphagic.
• Collect a stool specimen.

(1., 2., 3., & 5. Correct: Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen.

• Incorrect: This client has difficulty swallowing and is at risk for choking making

the client unstable. Therefore, the nurse should not allow the UAP to feed this client.)

Which nurse is providing cost effective care to a client?Select all that apply.

• Providing palliative care to a terminally ill client.
• Beginning discharge planning on admit.
• Counseling clients on cigarette smoking cessation.
• Educating a group of parents on the importance of

childhood immunizations.

• Performing a postop wound dressing change using

clean gloves.

• Providing palliative care to a terminally ill client.
• Beginning discharge planning on admit.
• Counseling clients on cigarette smoking cessation.
• Educating a group of parents on the importance of childhood immunizations.

(1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well- established interventions that are effective and also are cost-effective. Two

additional preventive interventions were found to be cost-saving: childhood

immunization and counseling adults on the use of low dose aspirin.

5. Incorrect. A postop surgical wound dressing change is a sterile procedure:

Sterile gloves are necessary and failure to use them could lead to infection, which would then increase the cost of care to a client.) The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client?

• An unexpected hospital admission can be very

stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends.

• I know how you feel. I will be sure to tell your night

nurse in shift report that you will probably need something to help you sleep tonight.

• An unexpected hospital admission can be very

stressful. Is there anyone who I can call for you?

• I can call your primary healthcare provider for you and

ask if you could go home today, then schedule another date for your hospital admission.

• An unexpected hospital admission can be very stressful. I will notify the case

manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends.(1. Correct: The case manager should be involved in coordinating the client's care from the date of admission in order to help the client navigate unexpected situations like a last-minute hospital admission. The ability to make telephone calls to notify family and friends will help to decrease the client's sudden sense of isolation from normal daily life, loss of control, and anxiety.

• Incorrect: Although sleeping medication may be warranted for this client, the

nurse neglects to offer a viable solution to the client's problem. The nursing interventions should focus on assisting the client to explore their feelings.

3. Incorrect: Although this is a helpful response, this answer does not include

notifying the case manager. The nurse should forward this request to the case manager who can identify client needs.

• Incorrect: Calling the primary healthcare provider is inappropriate, as the client

requires hospitalization now. The primary healthcare provider will determine if the client should be hospitalized.)