NCLEX Questions

NCLEX Questions (2019) 5.0 (1 review) Students also studied Terms in this set (32) Science MedicineNursing Save NCLEX Practice Questions Exam 1 40 terms J_NavPreview EAQ Community Health II Ch 1-10 & 1...10 terms Bernice_Harrower Preview Management Quiz 5 69 terms howardkathryn Preview Endocr 10 terms DeP An example of a nurse activity that best reflects the American Nurses Association's definition of nursing is

• treating dysrhythmias that occur in a patient in the

coronary care unit

• diagnosing a patient w/ a feeding tube as being @ risk

for aspiration

• Establishing protocols for treating patients in the

emergency department

• Providing antianxiety drugs for a patient who has

disturbed sleep patterns.

• Diagnosing a patient w/ a feeding tube as being @ risk for aspiration.

Rationale: The American Nurses Association (ANA) defines nursing as "the

protection, promotion, & optimization of health & abilities, prevention of illness & injury, alleviation of suffering through the diagnosis & treatment of human response, & advocacy in the care of individuals, families, communities, & populations." The nursing activity described in option A. is r/t the prevention of injury A nurse working on the medical-surgical unit @ an urban hospital would like to become certified in medical- surgical nursing. The nurse knows that this process would most likely require

• A bachelor's degree in nursing
• Formal education in advanced nursing practice
• Experience for a specific period in medical-surgical

nursing

• Membership in a medical-surgical nursing specialty

organization

• Experience for a specific period in medical-surgical nursing

Rationale: Certification in nursing specialties usually requires a certain amount of clinical experience

A nurse is providing care for a patient after right hip surgery. Within a pay-for-performance system, a critical role of the nurse is to

• ensure that care is provided using minimal amount of

supplies

• Discharge the patient @ completion of the # of

approved days of care

• Implement measure to decrease the risk of the patient

acquiring an infection

• Asses the patient's ability to pay for health care

services @ the time of admission

• Implement measures to decrease the risk of the patient acquiring an infection

Rationale: Pay-for-performance programs reimburse hospitals for performance

on quality-of-care measures. Payment for care can be withheld if a patient develop certain health conditions during the hospital stay or if something happens to the patient that is considered preventable.The nurse is assigned to care for a newly admitted patient. Number in order the steps for using the nursing process to prioritize care ______Evaluate whether the plan was effective ______Identify any health problems ______Collect patient information ______Carry out the plan ______Determine a plan of care

5, 2, 1, 4, 3

Rationale: The basic order of the nursing process is assessment, problem

identification, planning implementation, & evaluation The linkages among the NANDA-I nursing diagnoses, NOC patient outcomes, & NIC nursing interventions can be used to

• Evaluate patient outcomes
• Provide guides for planning care
• Predict the results of nursing care
• Shorten written care plans for individual patients
• Providing guides for planning care

Rationale: Standardized care plans offered by the North American Nursing

Diagnosis Association (NANDA), Nursing outcomes Classification (NOC), & Nursing Interventions Classification(NIC) groups may be used as guides for routine nursing care.The nurse is caring for a diabetic patient in the ambulatory surgical unit who has undergone debridement of an infected toe. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (CNA)?

• Check the patient's vital signs
• Monitor the patient's pain level
• Assess the patient's pain level
• Evaluate the patient's tibial & perdal pulses
• Check the patient's vital signs

Rationale: You may delegate routine measurement of vital signs on a stable

postoperative patient to unlicensed assistive personnel. Nursing interventions that require independent nursing knowledge, skill, or judgment, such as assessment & evaluation of care, are your responsibility & cannot be delegated

The nurse's role in addressing the National Patient Safety Goals established by The Joint Commission includes (select all that apply)

• Answering monitoring alarms in a timely manner
• Using side rails & alarm systems as necessary to

prevent patient falls

• Obtaining complete, accurate list of the pateint's

medications on admission

• Memorizing & implementing all the rules published by

The Joint Commission

• Encouraging patients to be actively involved in &

question their own health care

• Answering monitoring alarms in a timely manner
• Using side rails & alarm systems as necessary to prevent patient falls
• Obtain a complete, accurate list of the patient's medication on admission

Rationale: Review the National Patient Safety Goals in Table 1-5. The goals r/t the correct options are to reduce the risk of patient harm resulting from falls, reduce the occurrence of alarm fatigue, & to accurately & completely reconcile medications across the continuum of care Advantages of using informatics in health care delivery are (select all that apply)

• Reduced need for nurses in acute care
• Increased patient anonymity & confidentiality
• The ability to achieve & maintain high standards of care
• Access to standard plans of care for many health

problems

• Improved communication of the patient's health status

to the health care team

• The ability to achieve & maintain high standards of care
• Access to standard plans of care for many health problems
• Improved communication of the patient's health status to the health care team

Rationale: Informatics can improve the ability of the health care team to deliver high-quality care through facilitating communication of the patient's health status among the team members & enhancing access to standardized plans of care. With the increased use of informatics are new concerns regarding best practices for maintaining patient anonymity & confidentiality.When using evidence-based practice, the nurse

• Must use clinical practice guidelines developed by

national health agencies

• Should use finding from randomized controlled trials

to plan care for all patients

• Uses clinical decision making & judgement to

determine what evidence is appropriate for a specific clinical situation

• Statistically analyzes the relationship of nursing

interventions to patient outcomes to establish evidence for the most appropriate patient interventions

• Uses clinical decisions make & judgement to determine what evidence is

appropriate for a specific clinical situation Rationale: Evidence-based practice is the consistent use of the best evidence in combination w/ clinicain's expertise & patients' preferences & values to support clinical decision making A nurse is providing care for a patient who had a transurethral resection of his prostate this morning. The patient is receiving continuous bladder irrigation, & the urinary catheter is now occluded. The nurse is planning to contact the patient's health care provider & communicate using the SBAR (Situation, Background, Assessment, Recommendation) format. Which statement is a component of communication using SBAR?

• "What do you think could be causing this occlusion?"
• "I think that we should manually irrigate his catheter."
• "What do you know about this patient & his history?"
• "Could you please provide some direction for his

care?"

• "I think that we should manually irrigate his catheter."

Rationale: Proposing a recommendation is a component of the "R" component of SBAR communication. Asking the health care provider for possible contributing factors to the problem or for general direction may be appropriate in some circumstances, but these are not explicit components of SBAR. The nurse should briefly identify the patient & his circumstances, not ask an open-ended question regarding the health care provider's familiarity.

The nurse establishes priority & determines outcomes for an individual patient during which phase of the nursing process?

• Analysis
• Planning
• Evaluation
• Assessment
• Planning

Rationale: During the planning phase of the nursing process, patient outcomes or goals are developed & nursing interventions are identified to accomplish the outcomes. The assessment phase of the nursing process includes the collection of subjective & objective patient information on which to base the plan of care. The evaluation phase of the nursing process determines if the patient outcomes have been met as a result of nursing interventions. Nursing diagnosis is the act of analyzing the assessment data & making a judgement about the nature of the data.Telehealth devices are commonly used to provide which types of patient care (select all that apply)?

• Evaluation of weight loss
• Medication administration
• Video assessment of wounds
• Monitoring peak flow meter results
• Real-time blood pressure assessment
• Evaluation of weight loss
• Video assessment of wounds
• Monitoring peak flow meter results
• Real-time blood pressure assessment

Rationale: Telehealth enables the nurse to provide distance assessment, planning, intervention, & evaluation of outcomes of nursing care using technologies such as the internet, digital assessment tools, and telemonitoring equipment. Among the many uses of telehealth are monitoring patients w/ chronic or critical conditions & helping patient manage symptoms When planning care for a patient, the nurse may use a visual diagram of patient problems & interventions to illustrate the relationships among pertinent clinical data.This format is called a

• concept map
• Critical pathway
• Clinical pathway
• Nursing care plan
• concept map

Rationale:

A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in a visual diagram of patient problems & interventions. A clinical (critical) pathway is a prewritten plan that directs the entire interprofessional care team in the daily care goals for select health care problems Order the steps of the EBP process

• Share the outcomes
• Ask the clinical question
• Evaluate the practice decision or change.
• Critically appraise & synthesize evidence
• Thoroughly search for & collect evidence
• Integrate evidence-based recommendations into

practice

Ans: B, E, D, F, C, A

Rationale:

When there is a spirit of inquiry present, the steps of the EBP process can be undertaken. This problem-solving approach to clinical decision making involves (1) asking the clinical question w/ PICO(T) format, (2) gathering the best available evidence followed by critical appraisal & synthesis of the evidence found, & (3) integrating the evidence w/ clinical expertise & patient preference in making a practice decision or change. The outcomes are evaluated & then shared to influence nursing practice & patient care When nurses disagree about the effectiveness of a commonly practiced nursing intervention, the best evidence for determining which intervention to use is

• A systematic review of randomized controlled trials
• A qualitative research study with a large sample size
• A methodological internet search using key medical

terms

• Anecdotal evidence retrieved from 2 or more case

studies

• A systematic review of randomized controlled trials

Rationale:

Systematic reviews of randomized controlled trials (RCTs) are considered the

strongest level of evidence to answer questions about interventions (example:

cause & effect)